obesity and tka: optimization, management and …...obesity and tka: optimization, management and...

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Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F. Chen, MD, MBA Peter K. Sculco, MD Brett R. Levine, MD James I. Huddleston III, MD

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Page 1: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Obesity and TKA Optimization Management and Outcomes

April 8 2019715 PM

DirectorGregory J Golladay MD

FacultyAtonia F Chen MD MBA

Peter K Sculco MDBrett R Levine MD

James I Huddleston III MD

Disclosures

bullGregory Golladay MD (Richmond VA)bullSubmitted on 04012019bullAmerican Association of Hip and Knee Surgeons Board or committee member

bullArthroplasty Today Editorial or governing board Publishing royalties financial or material support

bullJournal of Arthroplasty Editorial or governing boardbullKCI Research supportbullOrthosensor Paid consultant Research supportbullOrthosensor Inc IP royaltiesbullOrthosensor Inc Paid presenter or speaker Stock or stock Options

bullVirginia Orthopaedic Society Board or committee member

Patient selection and optimization of obesity in TKA

Antonia F Chen MDMBADirector of Research Arthroplasty ServicesBrigham and Womenrsquos HospitalHarvard Medical School

DisclosuresAntonia F Chen MD MBA Submitted on 02132019bull 3M Paid consultantbull AAOS Board or committee memberbull ACI Paid consultantbull AJRR Board or committee memberbull American Association of Hip and Knee Surgeons Board

or committee memberbull American Medical Foundation Paid consultantbull Annals of Joint Editorial or governing boardbull bOne Paid consultantbull Bone amp Joint 360 Journal Editorial or governing boardbull Clinical Orthopaedics and Related Research Editorial or

governing boardbull Convatec Paid consultantbull DJ Orthopaedics Paid consultantbull European Knee Association Board or committee

memberbull Graftworx Stock or stock Optionsbull Halyard Research supportbull Haylard Paid consultantbull Healthcare Transformation Editorial or governing board

bull Heraeus Paid consultantbull Hyalex Stock or stock Optionsbull International Congress for Joint Reconstruction Board or

committee memberbull Irrimax Paid consultant Research supportbull Joint Purification Systems Stock or stock Optionsbull Journal of Arthroplasty Editorial or governing boardbull Journal of Bone amp Joint Infection Editorial or governing boardbull Knee Surgery Sports Traumatology Arthroscopy Editorial or

governing boardbull Musculoskeletal Infection Society Board or committee

memberbull Recro Paid consultantbull SLACK Incorporated Publishing royalties financial or material

supportbull Smith amp Nephew Research supportbull Sonoran Stock or stock Optionsbull Stryker Paid consultantbull Zimmer Paid consultant

Obesity Epidemic

Source CDC

Presenter
Presentation Notes
The rates of obesity has grown exponentially over the last two decades13By 2010 more than 72 million US adults were obese and no state had an obesity rate of less than 20 percent13With it the rates of comorbidities such as diabetes have also exponentially grown

Definition of Obesity

Increase rise of TKA in Obese patients

Patient presentation

bull Morbid obesity alone had increased wound dehiscence in-hospital infection GU complications extended stay facilities and in-hospital death

Wound Healingbull Increased dead space adipose tissue healing

bull BMI gt 40kgm2 = 22 wound complicationbull Normal BMI = 2 wound complication rate

Winiarskyet al JBJS J Bone Joint Surg Am 1998 Dec 0180(12)1770-4

Immunocompromised

Tateya et al Front Endocrinol (Lausanne) 2013 Aug 8493Increased pro-inflammatory cytokines

Presenter
Presentation Notes
Patients who are obese have increased circulating levels of pro-inflammatory proteins (TNF a and IL-6) which can impair immune function alter leucocyte counts (increases macrophages and B- cells and TH1 cells) and alter cell-mediated immune responses13Obesity leads to13(1) Increase in the production of leptin (pro-inflammatory) and the reduction in adiponectin (anti-inflammatory)13(2) NEFA can induce inflammation through modulation of adipokine production or activation of Toll-like receptors13(3) nutrient excess and adipocyte expansion trigger endoplasmic reticulum stress and 13(4) hypoxia occurring in hypertrophied adipose tissue stimulates the expression of inflammatory genes and activates immune cells13

Immunocompromised

Amar et al Proc Natl Acad Sci USA 2007 Dec 18104(51)20466-71

bull Mice infected with Porphyromonas gingivalis(common oral bacteria)

bull Mice with diet-induced obesity had higher bacteria count and greater alveolar bone loss and

Presenter
Presentation Notes
Studies have demonstrated that oral organisms have been found in orthopaedic infections of which Porphyromonas gingivalis (responsible for periodontitis) was used in a study comparing diet induced obese mice to lean mice13The study found that obese mice infected with Porphyromonas gingivalis had a lower ability to fight bacteria as indicated by a higher bacteria count and had greater alveolar bone loss

Immunocompromised

Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8

Obese patients have IL-1β IL-6 and TNF-α levels

Presenter
Presentation Notes
A study in total hip patients demonstrated that obese patients have increased IL-1B IL-6 and TNF-alpha after surgery

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

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Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

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Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

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Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 2: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Disclosures

bullGregory Golladay MD (Richmond VA)bullSubmitted on 04012019bullAmerican Association of Hip and Knee Surgeons Board or committee member

bullArthroplasty Today Editorial or governing board Publishing royalties financial or material support

bullJournal of Arthroplasty Editorial or governing boardbullKCI Research supportbullOrthosensor Paid consultant Research supportbullOrthosensor Inc IP royaltiesbullOrthosensor Inc Paid presenter or speaker Stock or stock Options

bullVirginia Orthopaedic Society Board or committee member

Patient selection and optimization of obesity in TKA

Antonia F Chen MDMBADirector of Research Arthroplasty ServicesBrigham and Womenrsquos HospitalHarvard Medical School

DisclosuresAntonia F Chen MD MBA Submitted on 02132019bull 3M Paid consultantbull AAOS Board or committee memberbull ACI Paid consultantbull AJRR Board or committee memberbull American Association of Hip and Knee Surgeons Board

or committee memberbull American Medical Foundation Paid consultantbull Annals of Joint Editorial or governing boardbull bOne Paid consultantbull Bone amp Joint 360 Journal Editorial or governing boardbull Clinical Orthopaedics and Related Research Editorial or

governing boardbull Convatec Paid consultantbull DJ Orthopaedics Paid consultantbull European Knee Association Board or committee

memberbull Graftworx Stock or stock Optionsbull Halyard Research supportbull Haylard Paid consultantbull Healthcare Transformation Editorial or governing board

bull Heraeus Paid consultantbull Hyalex Stock or stock Optionsbull International Congress for Joint Reconstruction Board or

committee memberbull Irrimax Paid consultant Research supportbull Joint Purification Systems Stock or stock Optionsbull Journal of Arthroplasty Editorial or governing boardbull Journal of Bone amp Joint Infection Editorial or governing boardbull Knee Surgery Sports Traumatology Arthroscopy Editorial or

governing boardbull Musculoskeletal Infection Society Board or committee

memberbull Recro Paid consultantbull SLACK Incorporated Publishing royalties financial or material

supportbull Smith amp Nephew Research supportbull Sonoran Stock or stock Optionsbull Stryker Paid consultantbull Zimmer Paid consultant

Obesity Epidemic

Source CDC

Presenter
Presentation Notes
The rates of obesity has grown exponentially over the last two decades13By 2010 more than 72 million US adults were obese and no state had an obesity rate of less than 20 percent13With it the rates of comorbidities such as diabetes have also exponentially grown

Definition of Obesity

Increase rise of TKA in Obese patients

Patient presentation

bull Morbid obesity alone had increased wound dehiscence in-hospital infection GU complications extended stay facilities and in-hospital death

Wound Healingbull Increased dead space adipose tissue healing

bull BMI gt 40kgm2 = 22 wound complicationbull Normal BMI = 2 wound complication rate

Winiarskyet al JBJS J Bone Joint Surg Am 1998 Dec 0180(12)1770-4

Immunocompromised

Tateya et al Front Endocrinol (Lausanne) 2013 Aug 8493Increased pro-inflammatory cytokines

Presenter
Presentation Notes
Patients who are obese have increased circulating levels of pro-inflammatory proteins (TNF a and IL-6) which can impair immune function alter leucocyte counts (increases macrophages and B- cells and TH1 cells) and alter cell-mediated immune responses13Obesity leads to13(1) Increase in the production of leptin (pro-inflammatory) and the reduction in adiponectin (anti-inflammatory)13(2) NEFA can induce inflammation through modulation of adipokine production or activation of Toll-like receptors13(3) nutrient excess and adipocyte expansion trigger endoplasmic reticulum stress and 13(4) hypoxia occurring in hypertrophied adipose tissue stimulates the expression of inflammatory genes and activates immune cells13

Immunocompromised

Amar et al Proc Natl Acad Sci USA 2007 Dec 18104(51)20466-71

bull Mice infected with Porphyromonas gingivalis(common oral bacteria)

bull Mice with diet-induced obesity had higher bacteria count and greater alveolar bone loss and

Presenter
Presentation Notes
Studies have demonstrated that oral organisms have been found in orthopaedic infections of which Porphyromonas gingivalis (responsible for periodontitis) was used in a study comparing diet induced obese mice to lean mice13The study found that obese mice infected with Porphyromonas gingivalis had a lower ability to fight bacteria as indicated by a higher bacteria count and had greater alveolar bone loss

Immunocompromised

Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8

Obese patients have IL-1β IL-6 and TNF-α levels

Presenter
Presentation Notes
A study in total hip patients demonstrated that obese patients have increased IL-1B IL-6 and TNF-alpha after surgery

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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ruct

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Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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onst

ruct

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Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

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Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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onst

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Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

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ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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onst

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Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

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Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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onst

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Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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Serv

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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Serv

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 3: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Patient selection and optimization of obesity in TKA

Antonia F Chen MDMBADirector of Research Arthroplasty ServicesBrigham and Womenrsquos HospitalHarvard Medical School

DisclosuresAntonia F Chen MD MBA Submitted on 02132019bull 3M Paid consultantbull AAOS Board or committee memberbull ACI Paid consultantbull AJRR Board or committee memberbull American Association of Hip and Knee Surgeons Board

or committee memberbull American Medical Foundation Paid consultantbull Annals of Joint Editorial or governing boardbull bOne Paid consultantbull Bone amp Joint 360 Journal Editorial or governing boardbull Clinical Orthopaedics and Related Research Editorial or

governing boardbull Convatec Paid consultantbull DJ Orthopaedics Paid consultantbull European Knee Association Board or committee

memberbull Graftworx Stock or stock Optionsbull Halyard Research supportbull Haylard Paid consultantbull Healthcare Transformation Editorial or governing board

bull Heraeus Paid consultantbull Hyalex Stock or stock Optionsbull International Congress for Joint Reconstruction Board or

committee memberbull Irrimax Paid consultant Research supportbull Joint Purification Systems Stock or stock Optionsbull Journal of Arthroplasty Editorial or governing boardbull Journal of Bone amp Joint Infection Editorial or governing boardbull Knee Surgery Sports Traumatology Arthroscopy Editorial or

governing boardbull Musculoskeletal Infection Society Board or committee

memberbull Recro Paid consultantbull SLACK Incorporated Publishing royalties financial or material

supportbull Smith amp Nephew Research supportbull Sonoran Stock or stock Optionsbull Stryker Paid consultantbull Zimmer Paid consultant

Obesity Epidemic

Source CDC

Presenter
Presentation Notes
The rates of obesity has grown exponentially over the last two decades13By 2010 more than 72 million US adults were obese and no state had an obesity rate of less than 20 percent13With it the rates of comorbidities such as diabetes have also exponentially grown

Definition of Obesity

Increase rise of TKA in Obese patients

Patient presentation

bull Morbid obesity alone had increased wound dehiscence in-hospital infection GU complications extended stay facilities and in-hospital death

Wound Healingbull Increased dead space adipose tissue healing

bull BMI gt 40kgm2 = 22 wound complicationbull Normal BMI = 2 wound complication rate

Winiarskyet al JBJS J Bone Joint Surg Am 1998 Dec 0180(12)1770-4

Immunocompromised

Tateya et al Front Endocrinol (Lausanne) 2013 Aug 8493Increased pro-inflammatory cytokines

Presenter
Presentation Notes
Patients who are obese have increased circulating levels of pro-inflammatory proteins (TNF a and IL-6) which can impair immune function alter leucocyte counts (increases macrophages and B- cells and TH1 cells) and alter cell-mediated immune responses13Obesity leads to13(1) Increase in the production of leptin (pro-inflammatory) and the reduction in adiponectin (anti-inflammatory)13(2) NEFA can induce inflammation through modulation of adipokine production or activation of Toll-like receptors13(3) nutrient excess and adipocyte expansion trigger endoplasmic reticulum stress and 13(4) hypoxia occurring in hypertrophied adipose tissue stimulates the expression of inflammatory genes and activates immune cells13

Immunocompromised

Amar et al Proc Natl Acad Sci USA 2007 Dec 18104(51)20466-71

bull Mice infected with Porphyromonas gingivalis(common oral bacteria)

bull Mice with diet-induced obesity had higher bacteria count and greater alveolar bone loss and

Presenter
Presentation Notes
Studies have demonstrated that oral organisms have been found in orthopaedic infections of which Porphyromonas gingivalis (responsible for periodontitis) was used in a study comparing diet induced obese mice to lean mice13The study found that obese mice infected with Porphyromonas gingivalis had a lower ability to fight bacteria as indicated by a higher bacteria count and had greater alveolar bone loss

Immunocompromised

Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8

Obese patients have IL-1β IL-6 and TNF-α levels

Presenter
Presentation Notes
A study in total hip patients demonstrated that obese patients have increased IL-1B IL-6 and TNF-alpha after surgery

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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ion

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ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

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ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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ion

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ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 4: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

DisclosuresAntonia F Chen MD MBA Submitted on 02132019bull 3M Paid consultantbull AAOS Board or committee memberbull ACI Paid consultantbull AJRR Board or committee memberbull American Association of Hip and Knee Surgeons Board

or committee memberbull American Medical Foundation Paid consultantbull Annals of Joint Editorial or governing boardbull bOne Paid consultantbull Bone amp Joint 360 Journal Editorial or governing boardbull Clinical Orthopaedics and Related Research Editorial or

governing boardbull Convatec Paid consultantbull DJ Orthopaedics Paid consultantbull European Knee Association Board or committee

memberbull Graftworx Stock or stock Optionsbull Halyard Research supportbull Haylard Paid consultantbull Healthcare Transformation Editorial or governing board

bull Heraeus Paid consultantbull Hyalex Stock or stock Optionsbull International Congress for Joint Reconstruction Board or

committee memberbull Irrimax Paid consultant Research supportbull Joint Purification Systems Stock or stock Optionsbull Journal of Arthroplasty Editorial or governing boardbull Journal of Bone amp Joint Infection Editorial or governing boardbull Knee Surgery Sports Traumatology Arthroscopy Editorial or

governing boardbull Musculoskeletal Infection Society Board or committee

memberbull Recro Paid consultantbull SLACK Incorporated Publishing royalties financial or material

supportbull Smith amp Nephew Research supportbull Sonoran Stock or stock Optionsbull Stryker Paid consultantbull Zimmer Paid consultant

Obesity Epidemic

Source CDC

Presenter
Presentation Notes
The rates of obesity has grown exponentially over the last two decades13By 2010 more than 72 million US adults were obese and no state had an obesity rate of less than 20 percent13With it the rates of comorbidities such as diabetes have also exponentially grown

Definition of Obesity

Increase rise of TKA in Obese patients

Patient presentation

bull Morbid obesity alone had increased wound dehiscence in-hospital infection GU complications extended stay facilities and in-hospital death

Wound Healingbull Increased dead space adipose tissue healing

bull BMI gt 40kgm2 = 22 wound complicationbull Normal BMI = 2 wound complication rate

Winiarskyet al JBJS J Bone Joint Surg Am 1998 Dec 0180(12)1770-4

Immunocompromised

Tateya et al Front Endocrinol (Lausanne) 2013 Aug 8493Increased pro-inflammatory cytokines

Presenter
Presentation Notes
Patients who are obese have increased circulating levels of pro-inflammatory proteins (TNF a and IL-6) which can impair immune function alter leucocyte counts (increases macrophages and B- cells and TH1 cells) and alter cell-mediated immune responses13Obesity leads to13(1) Increase in the production of leptin (pro-inflammatory) and the reduction in adiponectin (anti-inflammatory)13(2) NEFA can induce inflammation through modulation of adipokine production or activation of Toll-like receptors13(3) nutrient excess and adipocyte expansion trigger endoplasmic reticulum stress and 13(4) hypoxia occurring in hypertrophied adipose tissue stimulates the expression of inflammatory genes and activates immune cells13

Immunocompromised

Amar et al Proc Natl Acad Sci USA 2007 Dec 18104(51)20466-71

bull Mice infected with Porphyromonas gingivalis(common oral bacteria)

bull Mice with diet-induced obesity had higher bacteria count and greater alveolar bone loss and

Presenter
Presentation Notes
Studies have demonstrated that oral organisms have been found in orthopaedic infections of which Porphyromonas gingivalis (responsible for periodontitis) was used in a study comparing diet induced obese mice to lean mice13The study found that obese mice infected with Porphyromonas gingivalis had a lower ability to fight bacteria as indicated by a higher bacteria count and had greater alveolar bone loss

Immunocompromised

Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8

Obese patients have IL-1β IL-6 and TNF-α levels

Presenter
Presentation Notes
A study in total hip patients demonstrated that obese patients have increased IL-1B IL-6 and TNF-alpha after surgery

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

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Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

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Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

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Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

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Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 5: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Obesity Epidemic

Source CDC

Presenter
Presentation Notes
The rates of obesity has grown exponentially over the last two decades13By 2010 more than 72 million US adults were obese and no state had an obesity rate of less than 20 percent13With it the rates of comorbidities such as diabetes have also exponentially grown

Definition of Obesity

Increase rise of TKA in Obese patients

Patient presentation

bull Morbid obesity alone had increased wound dehiscence in-hospital infection GU complications extended stay facilities and in-hospital death

Wound Healingbull Increased dead space adipose tissue healing

bull BMI gt 40kgm2 = 22 wound complicationbull Normal BMI = 2 wound complication rate

Winiarskyet al JBJS J Bone Joint Surg Am 1998 Dec 0180(12)1770-4

Immunocompromised

Tateya et al Front Endocrinol (Lausanne) 2013 Aug 8493Increased pro-inflammatory cytokines

Presenter
Presentation Notes
Patients who are obese have increased circulating levels of pro-inflammatory proteins (TNF a and IL-6) which can impair immune function alter leucocyte counts (increases macrophages and B- cells and TH1 cells) and alter cell-mediated immune responses13Obesity leads to13(1) Increase in the production of leptin (pro-inflammatory) and the reduction in adiponectin (anti-inflammatory)13(2) NEFA can induce inflammation through modulation of adipokine production or activation of Toll-like receptors13(3) nutrient excess and adipocyte expansion trigger endoplasmic reticulum stress and 13(4) hypoxia occurring in hypertrophied adipose tissue stimulates the expression of inflammatory genes and activates immune cells13

Immunocompromised

Amar et al Proc Natl Acad Sci USA 2007 Dec 18104(51)20466-71

bull Mice infected with Porphyromonas gingivalis(common oral bacteria)

bull Mice with diet-induced obesity had higher bacteria count and greater alveolar bone loss and

Presenter
Presentation Notes
Studies have demonstrated that oral organisms have been found in orthopaedic infections of which Porphyromonas gingivalis (responsible for periodontitis) was used in a study comparing diet induced obese mice to lean mice13The study found that obese mice infected with Porphyromonas gingivalis had a lower ability to fight bacteria as indicated by a higher bacteria count and had greater alveolar bone loss

Immunocompromised

Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8

Obese patients have IL-1β IL-6 and TNF-α levels

Presenter
Presentation Notes
A study in total hip patients demonstrated that obese patients have increased IL-1B IL-6 and TNF-alpha after surgery

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

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Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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onst

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Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

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Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 6: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Definition of Obesity

Increase rise of TKA in Obese patients

Patient presentation

bull Morbid obesity alone had increased wound dehiscence in-hospital infection GU complications extended stay facilities and in-hospital death

Wound Healingbull Increased dead space adipose tissue healing

bull BMI gt 40kgm2 = 22 wound complicationbull Normal BMI = 2 wound complication rate

Winiarskyet al JBJS J Bone Joint Surg Am 1998 Dec 0180(12)1770-4

Immunocompromised

Tateya et al Front Endocrinol (Lausanne) 2013 Aug 8493Increased pro-inflammatory cytokines

Presenter
Presentation Notes
Patients who are obese have increased circulating levels of pro-inflammatory proteins (TNF a and IL-6) which can impair immune function alter leucocyte counts (increases macrophages and B- cells and TH1 cells) and alter cell-mediated immune responses13Obesity leads to13(1) Increase in the production of leptin (pro-inflammatory) and the reduction in adiponectin (anti-inflammatory)13(2) NEFA can induce inflammation through modulation of adipokine production or activation of Toll-like receptors13(3) nutrient excess and adipocyte expansion trigger endoplasmic reticulum stress and 13(4) hypoxia occurring in hypertrophied adipose tissue stimulates the expression of inflammatory genes and activates immune cells13

Immunocompromised

Amar et al Proc Natl Acad Sci USA 2007 Dec 18104(51)20466-71

bull Mice infected with Porphyromonas gingivalis(common oral bacteria)

bull Mice with diet-induced obesity had higher bacteria count and greater alveolar bone loss and

Presenter
Presentation Notes
Studies have demonstrated that oral organisms have been found in orthopaedic infections of which Porphyromonas gingivalis (responsible for periodontitis) was used in a study comparing diet induced obese mice to lean mice13The study found that obese mice infected with Porphyromonas gingivalis had a lower ability to fight bacteria as indicated by a higher bacteria count and had greater alveolar bone loss

Immunocompromised

Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8

Obese patients have IL-1β IL-6 and TNF-α levels

Presenter
Presentation Notes
A study in total hip patients demonstrated that obese patients have increased IL-1B IL-6 and TNF-alpha after surgery

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

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ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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onst

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Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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onst

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Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 7: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Increase rise of TKA in Obese patients

Patient presentation

bull Morbid obesity alone had increased wound dehiscence in-hospital infection GU complications extended stay facilities and in-hospital death

Wound Healingbull Increased dead space adipose tissue healing

bull BMI gt 40kgm2 = 22 wound complicationbull Normal BMI = 2 wound complication rate

Winiarskyet al JBJS J Bone Joint Surg Am 1998 Dec 0180(12)1770-4

Immunocompromised

Tateya et al Front Endocrinol (Lausanne) 2013 Aug 8493Increased pro-inflammatory cytokines

Presenter
Presentation Notes
Patients who are obese have increased circulating levels of pro-inflammatory proteins (TNF a and IL-6) which can impair immune function alter leucocyte counts (increases macrophages and B- cells and TH1 cells) and alter cell-mediated immune responses13Obesity leads to13(1) Increase in the production of leptin (pro-inflammatory) and the reduction in adiponectin (anti-inflammatory)13(2) NEFA can induce inflammation through modulation of adipokine production or activation of Toll-like receptors13(3) nutrient excess and adipocyte expansion trigger endoplasmic reticulum stress and 13(4) hypoxia occurring in hypertrophied adipose tissue stimulates the expression of inflammatory genes and activates immune cells13

Immunocompromised

Amar et al Proc Natl Acad Sci USA 2007 Dec 18104(51)20466-71

bull Mice infected with Porphyromonas gingivalis(common oral bacteria)

bull Mice with diet-induced obesity had higher bacteria count and greater alveolar bone loss and

Presenter
Presentation Notes
Studies have demonstrated that oral organisms have been found in orthopaedic infections of which Porphyromonas gingivalis (responsible for periodontitis) was used in a study comparing diet induced obese mice to lean mice13The study found that obese mice infected with Porphyromonas gingivalis had a lower ability to fight bacteria as indicated by a higher bacteria count and had greater alveolar bone loss

Immunocompromised

Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8

Obese patients have IL-1β IL-6 and TNF-α levels

Presenter
Presentation Notes
A study in total hip patients demonstrated that obese patients have increased IL-1B IL-6 and TNF-alpha after surgery

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

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Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

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Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

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Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

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Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 8: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Patient presentation

bull Morbid obesity alone had increased wound dehiscence in-hospital infection GU complications extended stay facilities and in-hospital death

Wound Healingbull Increased dead space adipose tissue healing

bull BMI gt 40kgm2 = 22 wound complicationbull Normal BMI = 2 wound complication rate

Winiarskyet al JBJS J Bone Joint Surg Am 1998 Dec 0180(12)1770-4

Immunocompromised

Tateya et al Front Endocrinol (Lausanne) 2013 Aug 8493Increased pro-inflammatory cytokines

Presenter
Presentation Notes
Patients who are obese have increased circulating levels of pro-inflammatory proteins (TNF a and IL-6) which can impair immune function alter leucocyte counts (increases macrophages and B- cells and TH1 cells) and alter cell-mediated immune responses13Obesity leads to13(1) Increase in the production of leptin (pro-inflammatory) and the reduction in adiponectin (anti-inflammatory)13(2) NEFA can induce inflammation through modulation of adipokine production or activation of Toll-like receptors13(3) nutrient excess and adipocyte expansion trigger endoplasmic reticulum stress and 13(4) hypoxia occurring in hypertrophied adipose tissue stimulates the expression of inflammatory genes and activates immune cells13

Immunocompromised

Amar et al Proc Natl Acad Sci USA 2007 Dec 18104(51)20466-71

bull Mice infected with Porphyromonas gingivalis(common oral bacteria)

bull Mice with diet-induced obesity had higher bacteria count and greater alveolar bone loss and

Presenter
Presentation Notes
Studies have demonstrated that oral organisms have been found in orthopaedic infections of which Porphyromonas gingivalis (responsible for periodontitis) was used in a study comparing diet induced obese mice to lean mice13The study found that obese mice infected with Porphyromonas gingivalis had a lower ability to fight bacteria as indicated by a higher bacteria count and had greater alveolar bone loss

Immunocompromised

Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8

Obese patients have IL-1β IL-6 and TNF-α levels

Presenter
Presentation Notes
A study in total hip patients demonstrated that obese patients have increased IL-1B IL-6 and TNF-alpha after surgery

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

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Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

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Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

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Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

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Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 9: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

bull Morbid obesity alone had increased wound dehiscence in-hospital infection GU complications extended stay facilities and in-hospital death

Wound Healingbull Increased dead space adipose tissue healing

bull BMI gt 40kgm2 = 22 wound complicationbull Normal BMI = 2 wound complication rate

Winiarskyet al JBJS J Bone Joint Surg Am 1998 Dec 0180(12)1770-4

Immunocompromised

Tateya et al Front Endocrinol (Lausanne) 2013 Aug 8493Increased pro-inflammatory cytokines

Presenter
Presentation Notes
Patients who are obese have increased circulating levels of pro-inflammatory proteins (TNF a and IL-6) which can impair immune function alter leucocyte counts (increases macrophages and B- cells and TH1 cells) and alter cell-mediated immune responses13Obesity leads to13(1) Increase in the production of leptin (pro-inflammatory) and the reduction in adiponectin (anti-inflammatory)13(2) NEFA can induce inflammation through modulation of adipokine production or activation of Toll-like receptors13(3) nutrient excess and adipocyte expansion trigger endoplasmic reticulum stress and 13(4) hypoxia occurring in hypertrophied adipose tissue stimulates the expression of inflammatory genes and activates immune cells13

Immunocompromised

Amar et al Proc Natl Acad Sci USA 2007 Dec 18104(51)20466-71

bull Mice infected with Porphyromonas gingivalis(common oral bacteria)

bull Mice with diet-induced obesity had higher bacteria count and greater alveolar bone loss and

Presenter
Presentation Notes
Studies have demonstrated that oral organisms have been found in orthopaedic infections of which Porphyromonas gingivalis (responsible for periodontitis) was used in a study comparing diet induced obese mice to lean mice13The study found that obese mice infected with Porphyromonas gingivalis had a lower ability to fight bacteria as indicated by a higher bacteria count and had greater alveolar bone loss

Immunocompromised

Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8

Obese patients have IL-1β IL-6 and TNF-α levels

Presenter
Presentation Notes
A study in total hip patients demonstrated that obese patients have increased IL-1B IL-6 and TNF-alpha after surgery

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

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Serv

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Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

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Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

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Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 10: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Wound Healingbull Increased dead space adipose tissue healing

bull BMI gt 40kgm2 = 22 wound complicationbull Normal BMI = 2 wound complication rate

Winiarskyet al JBJS J Bone Joint Surg Am 1998 Dec 0180(12)1770-4

Immunocompromised

Tateya et al Front Endocrinol (Lausanne) 2013 Aug 8493Increased pro-inflammatory cytokines

Presenter
Presentation Notes
Patients who are obese have increased circulating levels of pro-inflammatory proteins (TNF a and IL-6) which can impair immune function alter leucocyte counts (increases macrophages and B- cells and TH1 cells) and alter cell-mediated immune responses13Obesity leads to13(1) Increase in the production of leptin (pro-inflammatory) and the reduction in adiponectin (anti-inflammatory)13(2) NEFA can induce inflammation through modulation of adipokine production or activation of Toll-like receptors13(3) nutrient excess and adipocyte expansion trigger endoplasmic reticulum stress and 13(4) hypoxia occurring in hypertrophied adipose tissue stimulates the expression of inflammatory genes and activates immune cells13

Immunocompromised

Amar et al Proc Natl Acad Sci USA 2007 Dec 18104(51)20466-71

bull Mice infected with Porphyromonas gingivalis(common oral bacteria)

bull Mice with diet-induced obesity had higher bacteria count and greater alveolar bone loss and

Presenter
Presentation Notes
Studies have demonstrated that oral organisms have been found in orthopaedic infections of which Porphyromonas gingivalis (responsible for periodontitis) was used in a study comparing diet induced obese mice to lean mice13The study found that obese mice infected with Porphyromonas gingivalis had a lower ability to fight bacteria as indicated by a higher bacteria count and had greater alveolar bone loss

Immunocompromised

Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8

Obese patients have IL-1β IL-6 and TNF-α levels

Presenter
Presentation Notes
A study in total hip patients demonstrated that obese patients have increased IL-1B IL-6 and TNF-alpha after surgery

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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onst

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Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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onst

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ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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onst

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ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

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ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

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ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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ruct

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Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 11: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Immunocompromised

Tateya et al Front Endocrinol (Lausanne) 2013 Aug 8493Increased pro-inflammatory cytokines

Presenter
Presentation Notes
Patients who are obese have increased circulating levels of pro-inflammatory proteins (TNF a and IL-6) which can impair immune function alter leucocyte counts (increases macrophages and B- cells and TH1 cells) and alter cell-mediated immune responses13Obesity leads to13(1) Increase in the production of leptin (pro-inflammatory) and the reduction in adiponectin (anti-inflammatory)13(2) NEFA can induce inflammation through modulation of adipokine production or activation of Toll-like receptors13(3) nutrient excess and adipocyte expansion trigger endoplasmic reticulum stress and 13(4) hypoxia occurring in hypertrophied adipose tissue stimulates the expression of inflammatory genes and activates immune cells13

Immunocompromised

Amar et al Proc Natl Acad Sci USA 2007 Dec 18104(51)20466-71

bull Mice infected with Porphyromonas gingivalis(common oral bacteria)

bull Mice with diet-induced obesity had higher bacteria count and greater alveolar bone loss and

Presenter
Presentation Notes
Studies have demonstrated that oral organisms have been found in orthopaedic infections of which Porphyromonas gingivalis (responsible for periodontitis) was used in a study comparing diet induced obese mice to lean mice13The study found that obese mice infected with Porphyromonas gingivalis had a lower ability to fight bacteria as indicated by a higher bacteria count and had greater alveolar bone loss

Immunocompromised

Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8

Obese patients have IL-1β IL-6 and TNF-α levels

Presenter
Presentation Notes
A study in total hip patients demonstrated that obese patients have increased IL-1B IL-6 and TNF-alpha after surgery

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

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Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

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Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

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Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

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Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 12: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Immunocompromised

Amar et al Proc Natl Acad Sci USA 2007 Dec 18104(51)20466-71

bull Mice infected with Porphyromonas gingivalis(common oral bacteria)

bull Mice with diet-induced obesity had higher bacteria count and greater alveolar bone loss and

Presenter
Presentation Notes
Studies have demonstrated that oral organisms have been found in orthopaedic infections of which Porphyromonas gingivalis (responsible for periodontitis) was used in a study comparing diet induced obese mice to lean mice13The study found that obese mice infected with Porphyromonas gingivalis had a lower ability to fight bacteria as indicated by a higher bacteria count and had greater alveolar bone loss

Immunocompromised

Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8

Obese patients have IL-1β IL-6 and TNF-α levels

Presenter
Presentation Notes
A study in total hip patients demonstrated that obese patients have increased IL-1B IL-6 and TNF-alpha after surgery

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

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Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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ion

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ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

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Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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ion

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ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 13: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Immunocompromised

Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8

Obese patients have IL-1β IL-6 and TNF-α levels

Presenter
Presentation Notes
A study in total hip patients demonstrated that obese patients have increased IL-1B IL-6 and TNF-alpha after surgery

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

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ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 14: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Malnutrition

Huang et al J Arthroplasty 2013 Sep28(8 Suppl)21-4

bull BMI gt 30 kgm2 was present in 429 of malnourished patients

bull Significantly higher complication rate

Presenter
Presentation Notes
Multiple studies within medicine have shown that patients who are obese are malnourished which can predispose patients to infections13Obese patients often have a high-fat diet poor nutritional knowledge tend to overeat and often eat out13A study conducted from our institution found that 43 of malnourished patients as measured by low albumin and transferrin were obese with BMI gt 30kgm2 These patients also had significantly higher complication rates including infection13

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

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Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

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Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 15: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Malnutrition

ndash Albumin lt 35 gdLndash Prealbumin lt 18 mgdLndash Total protein lt 60 gdLndash Total lymphocyte count lt 1500 cellsmm3

ndash Iron lt 45 μgdLndash Serum transferrin lt200 mgdLndash 25-OH Vitamin D lt 30ngmL

Cross et al JAAOS 2014 Mar22(3)193-9

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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onst

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Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 16: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Malnutrition

Presenter
Presentation Notes
Besides the traditional measurements of malnutrition obese patients also tend to have deficiencies in nutrients as listed here

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 17: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Patient Optimization and Selection

bull Strict BMI criteria (lt 35 to 40 kgm2)bull Require Preoperative Weight Reductionbull Poss Nutrition consultbull Medical optimization

Inacio et al J Arthroplasty 2014 Mar29(3)458-64e1

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

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ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

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ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 18: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Body Fat measurement

bull Body mass index calculation

Air-displacement plethysmography

Skin calipers

DEXA scan

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

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ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

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ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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ruct

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ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 19: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Weight Reduction

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 20: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Intervention

Inacio etal JOA 2014 Feb 26

Revision surgery or 90-day readmission

Presenter
Presentation Notes
Bariatric surgery may help patients lose weight with gastric bypass and gastric banding as options13However the results are mixed A study conducted out of Kaiser in California found that bariatric surgery may not change the rate of revision surgery or 90-day readmission after TJA when compared to patients who received bariatric surgery (within 2 years of TJA or greater than 2 years before TJA) compared to those who did not undergo bariatric surgery13Reference Inacio MC Paxton EW Fisher D Li RA Barber TC Singh JA Bariatric Surgery Prior to Total Joint Arthroplasty May Not Provide Dramatic Improvements in Post-Arthroplasty Surgical Outcomes J Arthroplasty 2014 Feb 261313

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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onst

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Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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onst

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ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 21: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

TKA reduced short-term PJI (not THA)

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

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Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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onst

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ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 22: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

- Medicare 5 part B data (1999 to 2012)- Primary TKA = 86609 Primary THA = 47895- Patients with prior bariatric surgery before arthroplasty were

compared to patients with other common metabolic conditions

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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onst

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Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

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ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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onst

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Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 23: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Nutritional Supplementation

- 14 days prior to surgery - nutritional supplementation twice a day

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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onst

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Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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onst

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ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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onst

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ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 24: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Vitamin D

bull Vitamin D Level 10-30ngmLndash Vitamin D2 50000 IU PO x 4 weeksndash Vitamin D2 800 IU daily

bull Vitamin D Level lt10ngmLndash Endocrine consultndash Vitamin D2 50000 IU PO x 3 daysndash Three timeswk for 3 extra weeks (12 doses)

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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ruct

ion

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ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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onst

ruct

ion

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ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

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ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 25: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Medical Optimization

bull Cardiac diseasebull Renal diseasebull Peripheral vascular diseasebull Pulmonary circulation disordersbull Diabetes

ndash Strict HgbA1C criteria ndash Tightly controlled glucose

Harris et al J Arthroplasty 2013 Sep28(8 Suppl)25-9Jamsen et al JBJS 2012 Jul 1894(14)e101Bozic et al CORR 2012 Jan470(1)130-7

Presenter
Presentation Notes
Modifyable risk factors

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 26: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Diabetes

bull Surgical stress antagonizes insulinndash Predisposes patients to

hyperglycemiandash Impairs ability of leukocytes to

stop infectionndash Hyperglycemia predisposes

diabetic and nondiabetic patients to infection

Richards JBJS 2012 Stryker JBJS 2013)

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

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Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

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Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

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Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

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Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 27: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Diabetes

77Hemoglobin A1C

GOAL Maintain Glucose lt 200

Optimal blood glucose threshold

of 137 mgdL

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

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Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

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Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

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Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

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Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 28: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Conclusions- Obese patients have increased morbidity and

mortality after TKA- Preoperative intervention weight loss

nutritional management medical optimization

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

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Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

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Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

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Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

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Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 29: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Thank You

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

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onst

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ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 30: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Disclosures bull Consultant

ndash Lima Corporatendash EOS Imaging

bull Research Support ndash Intellijoint Surgical

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

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onst

ruct

ion

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ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 31: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Overview

bull Backgroundbull OR Set up + exposurebull Surgical tipsbull Implant fixationbull Minimize wound complications

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 32: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adult Obesity Prevalence

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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onst

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Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

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ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

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Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ion

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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onst

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ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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onst

ruct

ion

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ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 33: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Challenges of TKA in Obese Patients

bull Increased technical difficulty bull Increased operative time bull Increased infection risk (superficial and deep)bull Increased revisionaseptic loosening rate

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

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onst

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Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 34: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Li et al JBJS 2017

Methods6 months post TKA and THA data2964 TKAs

Pre and Post SF36 BMI gt 35 vs BMI lt 35

Presenter
Presentation Notes
2964 TKAs obese (gt 35 BMI vs non obese) similar improvement in pain

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

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Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

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ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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onst

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ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

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ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 35: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

BMI 40 BMI 50 BMI 60

Werner et al JOA 2015

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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ion

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ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

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onst

ruct

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Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

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ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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onst

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ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 36: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Periop OR Time Allocation

Gadinsky et al JOA 2012

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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ruct

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Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

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onst

ruct

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Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

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ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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onst

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ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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onst

ruct

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Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 37: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Peri-op Weight based Antibiotic Prophylaxis

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

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onst

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Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 38: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Set up and Exposurebull Leg holders lateral post supportive operative

tablesbull Careful tourniquet application (consider sterile

tourniquet) bull Longer incision bull Avoid tension on distal skin bull Minimize lateral flap (limit seromadeadspace) bull Medial parapatellar subvastus midvastus approach bull Consideration for leaving patella unresurfacedbull If patella cut early use metallic patella protector bull Additional retractors

42

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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ruct

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Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

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Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

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Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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onst

ruct

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Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 39: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Surgical Tipsbull Be careful of MCL and Patella tendon

avulsion injury bull Avoid excessive external rotation and

hyperflexionbull Remove osteophytes early (decompress)bull Consideration for completing all femoral

bone cuts FIRST (easier to expose the tibia)

bull Flexion gap assessed while pulling up on thigh

bull Careful assessment of terminal extension (look at components)

Liu et al J Knee Surg 2013

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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ruct

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Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

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onst

ruct

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Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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onst

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Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

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ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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onst

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ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 40: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Achieving Accurate Coronal Alignment in Obese TKA

Tibial Resection Options bull Extramedullary bull Intramedullary (maybe faster than

EM) bull Intraoperative x-raybull Possible benefit to use of

computer navigation ndash (93 within +- 3 deg with CAS vs

56 mechanical BMI gt 35) Lustig et al Knee Society 2016Lozano Obesity Surgery 2008Choong et al JOA 2009

Risk factors for Varus Tibial Resection

Preoperative Varus Increased BMI

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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onst

ruct

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Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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onst

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ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

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ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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ion

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 41: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Increased reported rates of bull Osteolysisbull Radiolucency bull Poly wearbull Malalignmentbull Component loosening bull Catastrophic tibia varus collapse with

elevated BMI

Fehring et al JOA 2017

Implant Fixation

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

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ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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onst

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ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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onst

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ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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onst

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Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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ruct

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ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 42: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

bull Small implant + High BMI = Fatigue failure of proximal tibia

bull Most tibial failures had bone stress gt 300000 Pascals

bull Recommend 30mm stem extension to decrease stress

46

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

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Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 43: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Gopalakrishnan J Knee Surgery 2011

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

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Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

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onst

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ion

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ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 44: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Methodsndash Retrospective review of 5088 TKAs ndash Incidence of tibial component aseptic loosening BMI

gt 35 vs lt 35

Abdel et al BJJ 2015

Results

At 15 years BMI gt 35 Tibial revision for aseptic loosening 2x higher

ALL tibial failures in implants WITHOUT stem extensions

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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onst

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Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

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ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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onst

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ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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onst

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ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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onst

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Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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onst

ruct

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Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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onst

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ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

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ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 45: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Methods

Cemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented

(unknown if stems used)

Results

Cemented 16 loosening (188) Cementless 1 loosening (09)

Sinicrope et al JOA 2018

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

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onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 46: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Case Example Cementless TKA in Morbidly Obese

50

67 yo female

8 year fustaged bilateral TKAWell fixed

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

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ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

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onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

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ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

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onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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onst

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ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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onst

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ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ion

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 47: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Infection Reduction Measures bull Antibiotic cement bull Dilute betadine or other anti-septic solution bull Water-tight multi-layered closure

ndash Arthrotomy interrupted combined with a running suture ndash Skin running monocryl but staples or nylon if skin tenuous ndash Skin sealant

bull Occlusive dressing bull Closed incision negative pressure wound therapy

51

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

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onst

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ion

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ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 48: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Watts et al JOA 2016

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

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onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 49: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Nam et al JAAOS 2015

Strong evidence exists to support the use of ciNPWT in high risk primary TKA

Reduced bull wound drainagebull Seromahematoma formationbull Edemabull Enhanced wound healingbull Cost

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

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onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 50: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Summary

bull Allocate appropriate operative resources bull Reduce peri-op infection risk with weight based antibiotics

anti-septic irrigation water-tight closure and ciNPWTbull Avoid excessive traction of MCLpatella distal skin with

long incision long arthrotomy femur first resection bull Tibia Stem extensions in BMI gt 35

(either 30-50mm cemented stem or uncemented long-stem) bull Growing evidence supporting use of uncemented tibial

component fixation in BMI gt 35

Thank you

Adul

t Rec

onst

ruct

ion

Serv

ice

Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

Adul

t Rec

onst

ruct

ion

Serv

ice

DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

Adul

t Rec

onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

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onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 51: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Thank you

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Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

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Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

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Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

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Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 52: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

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Complications of TKA in Obese Patients and Their

ManagementBrett Levine MD MS

Associate ProfessorRush University Medical Center

Service Line DirectorElmhurst Memorial Hospital

Center

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DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

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Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

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Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

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Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 53: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

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DisclosuresbullPaid Consultant

ndashLinkndashMeretendashMcGraw-HillndashMedactandashDJOndashExactech

bullResearch FundingndashZimmer-Biomet ndashArtelon

bull Royaltiesndash Human Kinetics ndash Slack Inc

bull Committeesndash AAOS Arthroplasty

Evaluation Committeendash AAHKS Research and

Patient Education Com

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Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

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Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

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Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

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Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

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What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

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Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

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PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 54: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

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onst

ruct

ion

Serv

ice

Topics bullWhat are common complications associated with obese patients and TKAbullIntraoperative ComplicationsbullPostoperative Complications

bull In-hospitalbull Post-hospital

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

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ruct

ion

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ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

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onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

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ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

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ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

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ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

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ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

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PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

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ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

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ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

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ion

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Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 55: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

Obesitybull Major health concern in USA

ndash20-52 of TKA cases are in obese patients

bull Associated with increased risk forndash DMndash Heart diseasendash HTNndash Poor nutritionndash Early mortality

ndash As well as the need for TKA

Presenter
Presentation Notes
Excellent gains are made with TKA in obese patientsmdashHowever complication rates are increased

Adul

t Rec

onst

ruct

ion

Serv

ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

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onst

ruct

ion

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ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

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ion

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PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

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onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

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onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

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onst

ruct

ion

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ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

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ion

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ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

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onst

ruct

ion

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ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 56: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

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onst

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ice

Intraoperative Complications

bull Difficult exposurendashLocal tissue injuryndashProlonged surgeryndashWound healing concerns

ndashExcessive traction on retractors

bull Component alignmentndashHard to find landmarks

ndashFighting local tissues for exposure

ndashBody habitus pushes tibia forward with flexion

bull Patella concernsndashFracturendashTendon injuries

Presenter
Presentation Notes
Krushell et al (2006)mdashmore complications but should still offer surgery to these patients Wound complications late revision and suboptimal alignment13

Adul

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onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

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onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

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onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

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onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

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onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

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ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

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onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

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ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

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onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 57: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

Difficult Exposuresbull Solutions

ndashUse larger incisionndashConsider medial parapatellar approach (easily extended)

ndashRespect the local soft tissuesndashFull thickness flapsndashLow threshold for Quad Snip if needed or conversion to extensile exposure

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 58: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

Component Alignment

bullSolutionsndashComponent Alignment

bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 59: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

Patella Concerns

bull SolutionsndashAvoid over-resectionndashDo not grab patella with towel clips

ndashAvoid excessive retraction on EM

ndashLeave patella unresurfaced

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 60: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

Postoperative Complications

bull Patellofemoral issuesndash Painndash Fracturendash Looseningndash Tendon ruptures

bull Wound healing problems

bull PJI

bull Medical Complicationsbull Readmission Concerns

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 61: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

In-Hospital Complications

bull DrsquoApuzzo et al (2015)ndashNIS Databasendash98410 (55) of database TKAs were morbidly obese

ndashHigher risk forbull In-hospital infection--024 v 017bull Wound dehiscencemdash011 v 008bull GU complicationsmdash060 v 044bull In-hospital mortalitymdash008 v 002bull Increased LOSmdash36 v 35 daysbull Cost--$15174 v $14715bull DC to SNFmdash40 v 30

ndashNo differences inbull VTEbull CV Eventsbull Respiratory complicationsbull GIbull CNSbull Hematomaseromabull Peripheral vascular

ndashObesity is an independent risk factor inpatient postop complications

Presenter
Presentation Notes
Matched study 91 were able to be matched to nonobese patient13BMI cutoff of 40 is not perfect and other factors comorbidities must be considered

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 62: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

What to do

bull Prevention is best medicinendashPreop weight lossndashNutrition optimizationndashDiabetes controlndashHome preparationndashPossible Preop PTndashIncentive spirometry and respiratory care

bull Other OptionsndashAvoid catherizationndashAvoid over-narcotizingndashEarly mobilizationndashMedical Co-management

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 63: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

Patellofemoral Issues

bull Difficult Problembull Leg Size

ndashMay push tibia anteriorly increasing PF compartment forces

bull Tendon RupturesndashMay start during surgery

ndashWeight can affect forces across the EM tendons

bull SolutionsndashNot many useful ones once a fracture or tendon rupture

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 64: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

Post-Hospital Complications

bullWound Healing bull InfectionbullMedical ComplicationsbullReadmissions

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 65: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

Wound Healing Problems

bullLarger rdquodead spacerdquo areabullWiniarsky et al (1998)

ndash22 wound complications in obese v 2

bullSolutionsndashDecrease dead spacemdashchange closure add superficial drain

ndashNegative-pressure wound vacuum therapy

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 66: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullNamba (2005)mdashHighly obese TKA patients with 11 infection rate compared to 03 in non-obesendash 52 of TKA cohort were obesendash Odds ratio was 67 times higher for highly obese group

ndash Possible factorsndash difficult exposure longer operative times poor vascularity and a weakened immune system

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 67: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bull Several studies have shown increased rate of PJI with increasing BMI

bull Watts et al (2014)ndashTwo-stage revision in these patients had a higher rate of failure

ndash32 v 11 re-revisionndash22 v 4 re-infectionndash51 v 16 re-operation

bull Personal ExperiencendashGreater wound complicationsbull Need for Flaps or Plastics

Closurebull Persistent Drainage

ndashExtensor mechanism complications

ndashMedical complicationsndashDC to SNFndashLate complications

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 68: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

PJI

bullManagementndashPrevention prevention preventionndashMeticulous sterile technique

bullPossibly partial drape and re-prepndashWeight based antibioticsndashPre-op screening and hibiclens bathsshowers

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 69: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullLehtonen et al (2018)mdashNSQIP Studyndash 137209 patientsndashHigher BMI categories were associated with significantly increased risk of readmission

ndash Morbidly obese with greater readmission ratemdash424

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 70: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions Concerns

bullReadmitted patients had a 58 vs 104 complication rate

bull324 medical complications and 256 surgical complications

bullNamba 2005ndash found 10 v 8 percent readmission rate with highly obesendash Higher rates of Diabetes with highly obese 21 v 12

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 71: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

Readmissions

bullPreventionndashProvide access to the officendashPre-emptive phone callsndashPreoperative EducationndashEndorse a family or friend member as coach

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 72: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Adul

t Rec

onst

ruct

ion

Serv

ice

Thank You For Your Attention

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 73: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Trends and Outcomes of TJA in the Obese Patient

James I Huddleston III MDAssociate Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Derek F Amanatullah MD PhDAssistant Professor of Orthopaedic Surgery

Department of Orthopaedic SurgeryStanford University Medical Center

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 74: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Disclosure

James Irvin Huddleston III MD (Redwood City CA)Submitted on 10062018AAOS Board or committee memberAmerican Association of Hip and Knee Surgeons Board or committee memberAmerican Knee Society Research supportBiomet Paid consultant Research supportCalifornia Joint Replacement Registry Board or committee member Paid consultantCorin USA Paid consultant Paid presenter or speaker Research supportExactech Inc IP royalties Paid consultant Paid presenter or speakerHip Society Board or committee memberJournal of Arthroplasty Editorial or governing boardKnee Society Board or committee memberPorosteon Paid consultant Stock or stock OptionsRobert Wood Johnson Foundation Research supportWolters Kluwer Health - Lippincott Williams amp Wilkins Publishing royalties financial or material supportZimmer Paid consultant Paid presenter or speaker

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 75: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Your Weight is about to Rise

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 76: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

What is Body Mass Index

Normal Overweight Obese I(moderate)

Obese II(severe)

Obese III(morbid)

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 77: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

An Epidemic

Finkelstein+ Am J Prev Med 2012

Presenter
Presentation Notes
Currently 23 overweight or obese 13 obese expected to increase to 50 in 2030

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 78: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

California 38332521Texas 26448193New York 19651127Florida 19552860Illinois 12882135Pennsylvania 12773801Ohio 11570808

Letrsquos Talk Absolute Numbers

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 79: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Obese All 81820525Obese Adults 68562082California 38332521Texas 26448193New York 19651127Florida 19552860Obese Children 13258443Illinois 12882135Pennsylvania 12773801Ohio 11570808

Number of Patients with Obesity in the US

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 80: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits

Addictive Brain Chemistry Portion Size

Presenter
Presentation Notes
Habits ndash eating and exercise13Chemistry ndash Dopamine pattern of addiction for Fat AND Sugar

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 81: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Hypertension

Thrombosis

Inflammation

Type 2 Diabetes

DyslipidemiaArthritis

Stroke Heart AttackPVD

Asthma

Cancer Adipsin

Resistin

Angiotensinogen TNFα

TNF szlig

IL6

EGF Adipose Tissue

PAI-1

FFA

prostaglandins

Insulin

Estrogen

Adiponectin

Leptin

Slide courtesy of Dr Robert Kushner Northwestern University

Lipotoxicity = Metabolic Syndrome

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 82: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Christakis+ NEJM 2007

Obesity is Social

Presenter
Presentation Notes
Framingham = Habits ndashgt Social Disease13More obese with time and social connection

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 83: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Except Airplane Seats

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 84: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Obesity is Expensive

Jacobson Center for Science and the Public Interest

Presenter
Presentation Notes
Yearly health care expenditures

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 85: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Weight is a Global Epidemic

Ng+ Lancet 2014

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 86: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Obesity is NOT the ONLY Epidemic

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 87: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Demand Total Joint Replacement

Kurtz+ JBJS 2014

3M Primary TKA by 2030500K Primary THA by 2030

300K Revision TKA by 203050K Revision THA by 2030

Presenter
Presentation Notes
3M TKA and 500K THA in 2030 corresponding 300K TKR and 50K THR

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 88: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

The Cost of Arthritis

bull $128 billionyear

bull $81 + $47 billionyearcare + lost earnings

bull 1 Cause of Disability

Yelin+ 2003

Presenter
Presentation Notes
73 yo active female femoral neck fracture

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 89: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Prevalence of Arthritis in Patients with Obesity

Losina+ AC+R 2013

Obese

Non-Obese

Presenter
Presentation Notes
Younger age

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 90: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

TKA in Patients with Obesity is Rising

Woon+ JOA 2016

Presenter
Presentation Notes
NHDS

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 91: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Complications with TJA in Obese Patients

bull Wound Healing ndash Superficial Infectionbull Deep Infectionbull Dislocation (ie Component Positioning)bull Aseptic Looseningbull Revision Surgerybull Ligament Rupturebull Deep Venous ThrombosisPulmonary Embolismbull Medical Complications (eg UTI MI etc)

Gino+ JBJS 2012DrsquoApuzzo+ CORR 2015Pulos+ JOA 2014

Watts+ CORR 2015Haverkamp+ Acta Orthop 2011

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 92: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Even More Complications in the Morbidly Obese

Dowsey+ JBJS 2010Issa+ JBJS 2016

TKA 1 year

THA 4 years

Presenter
Presentation Notes
If we specifically look at experience with unplanned readmissions for the obese and morbidly obese in the total knee replacement patient population there is a 106 and 228 unplanned readmission rate respectively That coupled with the significant increase in perioperative complications makes treating the obese and morbidly obese prior to any total joint replacement a very important factor to the overall success in outcomes long term If we go a step further and look at the super obese there is a 77 time increase in complications Getting a patient to a more healthy weight is important for a number of reasons This study again demonstrates significant increase in infections requiring a revision in the super obese population (45 times greater incidence than the non-obese) which could also greatly impact the overall readmission rate Especially if these infections happen within the first 90-days post primary replacement It is also important to maintain a healthy weight after implant because as this study demonstrates a decrease in overall implant survivorship 131313

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 93: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Kremers+ CORR 2014

Cost with THA in Obese Patients

Every 5 kgm2 = $850 Primary and $1350 Revision 90-day

Presenter
Presentation Notes
If BMI increases the incidence of perioperative complications then to break it down in dollars and centshellip The higher the BMI the higher the costs specifically shown here in the THATKA market shown here The complications and issues around the perioperative experience drive up those costs In fact Vincent et al reported that a high BMI was associated with a LOS 13 days longer and 21 higher total hospital charges than a low BMI in primary TKA 1313

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 94: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Does Obesity Affect the Time to Revision THA

bull Analyzed patients referred for revision THA to assess time fromprimary to revision THA and reason for THA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 257 revision THAs (245 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision THA pre-operative BMI and timefrom primary to revision THA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 95: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Increasing BMI Adversely Affects THA Survival

Electricwala+ JOA 2015

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 96: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Reason for Revision THA = Early Loosening

Presenter
Presentation Notes
13

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 97: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Obesity and Early THR for Loosening

Goodnough+ CORR Pending

NON-OBESEOBESE

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 98: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Does Obesity Affect the Time to Revision TKA

bull Analyzed patients referred for revision TKA to assess time fromprimary to revision THA and reason for TKA

bull Excluded if they did not have a date of primary surgerypreoperative BMI or a minimum of one year of follow-up

bull After exclusion 666 revision TKAs (650 patients) over 10 yearsfrom 2011-2013

bull Age gender reason for revision TKA pre-operative BMI and timefrom primary to revision TKA in years were identified

bull Fisher exact test and a p-value of 0005 after Bonferroni correctionfor multiple comparisons

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 99: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Implant Failure NOT Confined to the Obese

Electricwala+ JOA 2015

BMI le 25

BMI gt 25

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 100: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Early Revision for Infection in Total Knee

Electricwala+ JOA 2015

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p

-

value

Acute

(lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute

(lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute

(lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute

(lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute

(lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early

(1

-

5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early

(1

-

5 years)

Infection

833 (24)

74138

(54)

0003

Early

(1

-

5 years)

Instability

716 (44)

76133 (57)

0425

Early

(1

-

5 years)

Stiffness

610 (60)

4176 (54)

1000

Early

(1

-

5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid

(5

-

10 years)

Aseptic looseningosteolysis

720

(35)

33130 (25)

0417

Mid

(5

-

10 years)

Infection

533 (15)

21138 (15)

1000

Mid

(5

-

10 years)

Instability

416 (25)

25133 (19)

0517

Mid

(5

-

10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid

(5

-

10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late

(gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late

(gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late

(gt10 years)

Instability

416 (25)

12133 (9)

0073

Late

(gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late

(gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Time of Revision Reason for Revision Normal BMI Elevated BMI p-value

Acute (lt1 year) Aseptic looseningosteolysis 020 (0) 4130 (3) 1000

Acute (lt1 year) Infection 1033 (30) 31138 (22) 1000

Acute (lt1 year) Instability 116 (6) 20133 (15) 0472

Acute (lt1 year) Stiffness 110 (10) 1776 (22) 0681

Acute (lt1 year) Miscellaneous 212 (17) 1798 (17) 1000

Early (1-5 years) Aseptic looseningosteolysis 820 (40) 55130 (42) 1000

Early (1-5 years) Infection 833 (24) 74138 (54) 0003

Early (1-5 years) Instability 716 (44) 76133 (57) 0425

Early (1-5 years) Stiffness 610 (60) 4176 (54) 1000

Early (1-5 years) Miscellaneous 612 (50) 5498 (55) 0767

Mid (5-10 years) Aseptic looseningosteolysis 720 (35) 33130 (25) 0417

Mid (5-10 years) Infection 533 (15) 21138 (15) 1000

Mid (5-10 years) Instability 416 (25) 25133 (19) 0517

Mid (5-10 years) Stiffness 210 (20) 1276 (16) 0664

Mid (5-10 years) Miscellaneous 112 (8) 1398 (13) 1000

Late (gt10 years) Aseptic looseningosteolysis 520 (25) 38130 (29) 0796

Late (gt10 years) Infection 1033 (30) 12138 (9) 0002

Late (gt10 years) Instability 416 (25) 12133 (9) 0073

Late (gt10 years) Stiffness 110 (10) 676 (8) 1000

Late (gt10 years) Miscellaneous 312 (25) 1498 (14) 0393

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer

Time of Revision

Reason for Revision

Normal BMI

Elevated BMI

p-value

Acute (lt1 year)

Aseptic looseningosteolysis

020 (0)

4130 (3)

1000

Acute (lt1 year)

Infection

1033 (30)

31138 (22)

1000

Acute (lt1 year)

Instability

116 (6)

20133 (15)

0472

Acute (lt1 year)

Stiffness

110 (10)

1776 (22)

0681

Acute (lt1 year)

Miscellaneous

212 (17)

1798 (17)

1000

Early (1-5 years)

Aseptic looseningosteolysis

820 (40)

55130 (42)

1000

Early (1-5 years)

Infection

833 (24)

74138 (54)

0003

Early (1-5 years)

Instability

716 (44)

76133 (57)

0425

Early (1-5 years)

Stiffness

610 (60)

4176 (54)

1000

Early (1-5 years)

Miscellaneous

612 (50)

5498 (55)

0767

Mid (5-10 years)

Aseptic looseningosteolysis

720 (35)

33130 (25)

0417

Mid (5-10 years)

Infection

533 (15)

21138 (15)

1000

Mid (5-10 years)

Instability

416 (25)

25133 (19)

0517

Mid (5-10 years)

Stiffness

210 (20)

1276 (16)

0664

Mid (5-10 years)

Miscellaneous

112 (8)

1398 (13)

1000

Late (gt10 years)

Aseptic looseningosteolysis

520 (25)

38130 (29)

0796

Late (gt10 years)

Infection

1033 (30)

12138 (9)

0002

Late (gt10 years)

Instability

416 (25)

12133 (9)

0073

Late (gt10 years)

Stiffness

110 (10)

676 (8)

1000

Late (gt10 years)

Miscellaneous

312 (25)

1498 (14)

0393

Page 101: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Wagner+ JBJS 2016

Relative Risk Increases EXPONENTIALLY

Every 1 kgm2 = 10 increase in relative risk of infection

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer
Page 102: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Houdek+ JBJS 2015

Poor After Revision for Infection

Non-Obese

Obese

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer
Page 103: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Just Lose Weighthellip

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer
Page 104: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Total Joint Replacement ne Weight Loss

Ast+ JBJS 2015

About 5-35 Loose 55-80 Same 5-15 Gain

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer
Page 105: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

0102030405060708090

100

0 10 20 30 40 50Weeks after commencement of program

R

eten

tion

Rat

e

Attrition from Weight Reduction Programs

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer
Page 106: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

190

226

60 50

22

264

05

96

151

64

18 23

142

0500

50

100

150

200

250

300

TKA Morbidly Obese (n=11294) TKA After Bariatric Surgery (n=219)

TKA Complications after Bariatric Surgery

Werner+ JOA 2015

Presenter
Presentation Notes
There is clear evidence treatment for the obese population prior to total joint replacement has significant increase in success of the procedure Weight loss of greater than 5 TBW is considered clinically significant weight loss So for the Class I and II obese patient (BMI 30-399) a non-surgical lifestyle management approach could still be highly effective at reducing any potential perioperative complications for the class IV obese patient (BMI ge 40) a surgical approach may offer a better more effective way to approach their disease

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer
Page 107: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Weight Loss Matters AFTER Joint Replacement

Lim+ JBJS Submitted

Weight LossWeight GainStable

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer
Page 108: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Giori Amanatullah Gupta Bowe and Harris JBJS 2018

Are BMI Cut-offs Really an Answer

Presenter
Presentation Notes
27671 TJA in VA System 1011 to 914 (3 years) - Major complications were defined as 30-day readmission reoperation cardiac arrest myocardial infarction (MI) coma cerebrovascular accident (CVA) peripheral nerve injury bleeding requiring more than 4 units packed red blood cells deep vein thrombosis pulmonary embolism prosthesis failure systemic sepsis failure to wean from the ventilator pneumonia re-intubation progressive renal insufficiency wound dehiscence deep infection and death within 90 days of surgery

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer
Page 109: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Is BMI Really the Answer

Wu+ JOA 2016

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer
Page 110: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

The ArthritisObesity Dilemma

bull More and more overweightobese patients arevisiting the orthopaedic surgeon for jointreplacement EXPONENTIAL DEMAND

bull They have tried nearly everything to lose weightwithout success FRUSTRATIONDENIAL

bull Doctors hospitals and payers will be reluctant toperformapprove joint replacement surgery forobese patients COSTSCOMPLICATIONS

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer
Page 111: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

THANK YOU

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer
Page 112: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Question amp Answer

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
  • Slide Number 38
  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
  • Slide Number 45
  • Slide Number 46
  • Slide Number 47
  • Slide Number 48
  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
  • Slide Number 52
  • Slide Number 53
  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
  • Slide Number 79
  • Slide Number 80
  • Slide Number 81
  • Slide Number 82
  • Slide Number 83
  • Slide Number 84
  • Slide Number 85
  • Slide Number 86
  • Slide Number 87
  • Slide Number 88
  • Obesity is Expensive
  • Slide Number 90
  • Slide Number 91
  • Slide Number 92
  • Slide Number 93
  • Slide Number 94
  • Slide Number 95
  • Slide Number 96
  • Slide Number 97
  • Slide Number 98
  • Slide Number 99
  • Slide Number 100
  • Slide Number 101
  • Slide Number 102
  • Slide Number 103
  • Slide Number 104
  • Slide Number 105
  • Slide Number 106
  • Slide Number 107
  • Slide Number 108
  • Slide Number 109
  • Slide Number 110
  • Slide Number 111
  • Slide Number 112
  • Slide Number 113
  • Slide Number 114
  • Slide Number 115
  • Slide Number 116
  • Question amp Answer
Page 113: Obesity and TKA: Optimization, Management and …...Obesity and TKA: Optimization, Management and Outcomes April 8, 2019 7:15 PM Director Gregory J. Golladay, MD Faculty Atonia F

Thank you for attending this eveningrsquos webinarA recording of tonightrsquos presentation will be available in 7-10 days

You will be notified by email when it is ready for viewing

  • Obesity and TKA Optimization Management and OutcomesApril 8 2019715 PMDirectorGregory J Golladay MDFacultyAtonia F Chen MD MBAPeter K Sculco MDBrett R Levine MDJames I Huddleston III MD
  • Disclosures
  • Slide Number 3
  • Disclosures
  • Obesity Epidemic
  • Definition of Obesity
  • Increase rise of TKA in Obese patients
  • Patient presentation
  • Slide Number 9
  • Slide Number 10
  • Wound Healing
  • Immunocompromised
  • Immunocompromised
  • Immunocompromised
  • Malnutrition
  • Malnutrition
  • Malnutrition
  • Patient Optimization and Selection
  • Body Fat measurement
  • Weight Reduction
  • Intervention
  • Slide Number 22
  • Slide Number 23
  • Slide Number 24
  • Nutritional Supplementation
  • Vitamin D
  • Medical Optimization
  • Diabetes
  • Diabetes
  • Conclusions
  • Thank You
  • Slide Number 32
  • Disclosures
  • Overview
  • Slide Number 35
  • Slide Number 36
  • Challenges of TKA in Obese Patients
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  • BMI 40
  • Periop OR Time Allocation
  • Peri-op Weight based Antibiotic Prophylaxis
  • Set up and Exposure
  • Surgical Tips
  • Achieving Accurate Coronal Alignment in Obese TKA
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  • MethodsCemented vs Cementless TKA (PS)Same design BMI gt 40min fu 5 years 108 cementless85 cemented(unknown if stems used)ResultsCemented 16 loosening (188) Cementless 1 loosening (09)
  • Case Example Cementless TKA in Morbidly Obese
  • Infection Reduction Measures
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  • Summary
  • Thank you
  • Complications of TKA in Obese Patients and Their Management
  • Disclosures
  • Topics
  • Obesity
  • Intraoperative Complications
  • Difficult Exposures
  • Component Alignment
  • Patella Concerns
  • Postoperative Complications
  • In-Hospital Complications
  • What to do
  • Patellofemoral Issues
  • Post-Hospital Complications
  • Wound Healing Problems
  • PJI
  • PJI
  • PJI
  • Readmissions Concerns
  • Readmissions Concerns
  • Readmissions
  • Thank You For Your Attention
  • Slide Number 77
  • Disclosure
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  • Obesity is Expensive
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  • Question amp Answer