obesity and tka: optimization, management and …...obesity and tka: optimization, management and...
TRANSCRIPT
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
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
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
Immunocompromised
Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8
Obese patients have IL-1β IL-6 and TNF-α levels
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
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
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
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
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
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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ice
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
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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
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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
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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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Immunocompromised
Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8
Obese patients have IL-1β IL-6 and TNF-α levels
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
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Immunocompromised
Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8
Obese patients have IL-1β IL-6 and TNF-α levels
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
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Immunocompromised
Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8
Obese patients have IL-1β IL-6 and TNF-α levels
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
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
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
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
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
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
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
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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
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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
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
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Component Alignment
bullSolutionsndashComponent Alignment
bullConsider IM guidesbullComputer navigationbullCustom cutting guidesbullIntraoperative fluoroscopy and placement of markers
Adul
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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
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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
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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
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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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Obesity Epidemic
Source CDC
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
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
Immunocompromised
Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8
Obese patients have IL-1β IL-6 and TNF-α levels
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
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
Immunocompromised
Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8
Obese patients have IL-1β IL-6 and TNF-α levels
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
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
Immunocompromised
Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8
Obese patients have IL-1β IL-6 and TNF-α levels
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
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
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
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
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
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
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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
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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
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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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
Immunocompromised
Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8
Obese patients have IL-1β IL-6 and TNF-α levels
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
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
Immunocompromised
Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8
Obese patients have IL-1β IL-6 and TNF-α levels
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
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
Immunocompromised
Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8
Obese patients have IL-1β IL-6 and TNF-α levels
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
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
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
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
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
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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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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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
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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
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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
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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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Immunocompromised
Tateya et al Front Endocrinol (Lausanne) 2013 Aug 8493Increased pro-inflammatory cytokines
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
Immunocompromised
Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8
Obese patients have IL-1β IL-6 and TNF-α levels
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
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
Immunocompromised
Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8
Obese patients have IL-1β IL-6 and TNF-α levels
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
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Immunocompromised
Motaghedi et al Clin Orthop Relat Res 2014 May472(5)1442-8
Obese patients have IL-1β IL-6 and TNF-α levels
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
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
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
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
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
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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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
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
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
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
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
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onst
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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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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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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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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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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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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
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
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
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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onst
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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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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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Malnutrition
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Weight Reduction
Intervention
Inacio etal JOA 2014 Feb 26
Revision surgery or 90-day readmission
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Intervention
Inacio etal JOA 2014 Feb 26
Revision surgery or 90-day readmission
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
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
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
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
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
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
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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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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
- 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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Li et al JBJS 2017
Methods6 months post TKA and THA data2964 TKAs
Pre and Post SF36 BMI gt 35 vs BMI lt 35
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
What is Body Mass Index
Normal Overweight Obese I(moderate)
Obese II(severe)
Obese III(morbid)
An Epidemic
Finkelstein+ Am J Prev Med 2012
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
An Epidemic
Finkelstein+ Am J Prev Med 2012
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Causes of the Obesity EpidemicAffluent Sedentary Society Poor Childhood Habits
Addictive Brain Chemistry Portion Size
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Christakis+ NEJM 2007
Obesity is Social
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Except Airplane Seats
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Obesity is Expensive
Jacobson Center for Science and the Public Interest
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
The Cost of Arthritis
bull $128 billionyear
bull $81 + $47 billionyearcare + lost earnings
bull 1 Cause of Disability
Yelin+ 2003
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Prevalence of Arthritis in Patients with Obesity
Losina+ AC+R 2013
Obese
Non-Obese
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
TKA in Patients with Obesity is Rising
Woon+ JOA 2016
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Even More Complications in the Morbidly Obese
Dowsey+ JBJS 2010Issa+ JBJS 2016
TKA 1 year
THA 4 years
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
Kremers+ CORR 2014
Cost with THA in Obese Patients
Every 5 kgm2 = $850 Primary and $1350 Revision 90-day
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
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
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
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
Increasing BMI Adversely Affects THA Survival
Electricwala+ JOA 2015
Reason for Revision THA = Early Loosening
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
Reason for Revision THA = Early Loosening
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
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
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
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
Early Revision for Infection in Total Knee
Electricwala+ JOA 2015
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
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
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
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- 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
-
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
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
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
-
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
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
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
-
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
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
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
-
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
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
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
-
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
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
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
-
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
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
-
Giori Amanatullah Gupta Bowe and Harris JBJS 2018
Are BMI Cut-offs Really an Answer
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
-
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
-
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
-
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
-
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
-
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
-