The outcomes of total knee arthroplasty in morbidly obese patients: a systematic review of the literature

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Abstract

Introduction

The increasing prevalence of obesity has led to an increase in total knee arthroplasties (TKAs) being undertaken in patients with a higher body mass index (BMI). TKA in morbidly obese patients can be technically challenging due to numerous anatomical factors and patient co-morbidities. The long-term outcomes in this patient group are unclear. This systematic review aims to compare the long-term revision rates, functional outcomes and complication rates of TKAs in morbidly obese versus non-obese patients.

Methods

A search of PubMed, EMBASE and PubMed Central was conducted to identify studies that reported revision rates in a cohort of morbidly obese patients (BMI ≥ 40 kg/m ²) that underwent primary TKA, compared to non-obese patients (BMI ≤ 30 kg/m ²). Secondary outcomes included Knee Society Objective Scores (KSOS), Knee Society Functional Scores (KSFS), and complication rates between the two groups. The difference in revision rates was assessed using the Chi-squared test. The Wilcoxon signed-rank test was used to compare pre-operative and post-operative functional scores for each group. KSOS and KSFS for morbidly obese and non-obese patients were compared using the Mann–Whitney test. Statistical significance was defined as p ≤ 0.05.

Results

Nine studies were included in this review. There were 624 TKAs in morbidly obese patients and 9,449 TKAs in non-obese patients, average BMI values were 45.0 kg/m ² (range 40–66 kg/m ²) and 26.5 kg/m ² (range 11–30 kg/m ²) respectively. The average follow-up time was 4.8 years (range 0.5–14.1) and 5.2 years (range 0.5–13.2) respectively, with a revision rate of 7% and 2% ( p < 0.001) respectively. All functional scores improved after TKA ( p < 0.001). Pre- and post-operative KSOS and KSFS were poorer in morbidly obese patients, however, mean improvement in KSOS was the same in both groups and comparable between groups for KSFS ( p = 0.78). Overall complication rates, including infection, were higher in morbidly obese patients.

Conclusions

This review suggests an increased mid to long-term revision rate following primary TKA in morbidly obese patients, however, these patients have a functional recovery which is comparable to non-obese individuals. There is also an increased risk of perioperative complications, such as superficial wound infection. Morbidly obese patients should be fully informed of these issues prior to undergoing primary TKA.

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Most cited references 35

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The influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review.

Warren Dunn, Gino Kerkhoffs, Diane Dahm … (2012)

The increase in the number of individuals with an unhealthy high body weight is particularly relevant in the United States. Obesity (body mass index ≥ 30 kg/m2) is a well-documented risk factor for the development of osteoarthritis. Furthermore, an increased prevalence of total knee arthroplasty in obese individuals has been observed in the last decades. The primary aim of this systematic literature review was to determine whether obesity has a negative influence on outcome after primary total knee arthroplasty. A search of the literature was performed, and studies comparing the outcome of total knee arthroplasty in different weight groups were included. The methodology of the included studies was scored according to the Cochrane guidelines. Data extraction and pooling were performed. The weighted mean difference for continuous data and the weighted odds ratio for dichotomous variables were calculated. Heterogeneity was calculated with use of the I2 statistic. After consensus was reached, twenty studies were included in the data analysis. The presence of any infection was reported in fourteen studies including 15,276 patients (I2, 26%). Overall, infection occurred more often in obese patients, with an odds ratio of 1.90 (95% confidence interval [CI], 1.46 to 2.47). Deep infection requiring surgical debridement was reported in nine studies including 5061 patients (I2, 0%). Deep infection occurred more often in obese patients, with an odds ratio of 2.38 (95% CI, 1.28 to 4.55). Revision of the total knee arthroplasty, defined as exchange or removal of the components for any reason, was documented in eleven studies including 12,101 patients (I2, 25%). Revision for any reason occurred more often in obese patients, with an odds ratio of 1.30 (95% CI, 1.02 to 1.67). Obesity had a negative influence on outcome after total knee arthroplasty.

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Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates.

Robert Malinzak, Merrill A Ritter, Michael Berend … (2009)

The study aims to delineate the deep infection rates and infection risk factors for primary total knee and total hip arthroplasty patients. A retrospective review was conducted on 6108 patients from 1991 to 2004. The deep infection cases were compared to the noninfected cohort whereby infection risk factors were identified. Of the 8494 joint arthroplasties, 43 (0.51%) developed a deep infection (30 total knee arthroplasties, 13 total hip arthroplasties). Patients with a body mass index greater than 50 had an increased odds ratio of infection of 21.3 (P < .0001). Diabetic patients were 3 times as likely to become infected compared to nondiabetic patients (P = .0027). Simultaneous bilateral total joint arthroplasties were found to have developed infection 3 times less frequently than those performed as unilateral procedures (P = .0024). The average age in our infection cohort was 64.3 and 68.4 in the noninfected cohort. In this retrospective review study, obesity, diabetes, and younger age were found to be risk factors for joint arthroplasty infection.

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Obesity decreases perioperative tissue oxygenation.

Barbara Kabon, Daniel Sessler, A Nagele … (2004)

Obesity is an important risk factor for surgical site infections. The incidence of surgical wound infections is directly related to tissue perfusion and oxygenation. Fat tissue mass expands without a concomitant increase in blood flow per cell, which might result in a relative hypoperfusion with decreased tissue oxygenation. Consequently, the authors tested the hypotheses that perioperative tissue oxygen tension is reduced in obese surgical patients. Furthermore, they compared the effect of supplemental oxygen administration on tissue oxygenation in obese and nonobese patients. Forty-six patients undergoing major abdominal surgery were assigned to one of two groups according to their body mass index: body mass index less than 30 kg/m2 (nonobese) or 30 kg/m2 or greater (obese). Intraoperative oxygen administration was adjusted to arterial oxygen tensions of approximately 150 mmHg and approximately 300 mmHg in random order. Anesthesia technique and perioperative fluid management were standardized. Subcutaneous tissue oxygen tension was measured with a polarographic electrode positioned within a subcutaneous tonometer in the lateral upper arm during surgery, in the recovery room, and on the first postoperative day. Postoperative tissue oxygen was also measured adjacent to the wound. Data were compared with unpaired two-tailed t tests and Wilcoxon rank sum test; P < 0.05 was considered statistically significant. Intraoperative subcutaneous tissue oxygen tension was significantly less in the obese patients at baseline (36 vs. 57 mmHg; P = 0.002) and with supplemental oxygen administration (47 vs. 76 mmHg; P = 0.014). Immediate postoperative tissue oxygen tension was also significantly less in subcutaneous tissue of the upper arm (43 vs. 54 mmHg; P = 0.011) as well as near the incision (42 vs. 62 mmHg; P = 0.012) in obese patients. In contrast, tissue oxygen tension was comparable in each group on the first postoperative morning. Wound and tissue hypoxia were common in obese patients in the perioperative period and most pronounced during surgery. Even with supplemental oxygen tissue, oxygen tension in obese patients was reduced to levels that are associated with a substantial increase in infection risk.

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Author and article information

Contributors

Sammy A. Hanna: sammy.hanna@bartshealth.nhs.uk

Journal

Journal ID (nlm-ta): Arch Orthop Trauma Surg

Journal ID (iso-abbrev): Arch Orthop Trauma Surg

Title: Archives of Orthopaedic and Trauma Surgery

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0936-8051

ISSN (Electronic): 1434-3916

Publication date (Electronic): 16 February 2019

Publication date PMC-release: 16 February 2019

Publication date (Print): 2019

Volume: 139

Issue: 4

Pages: 553-560

Affiliations

[1 ]ISNI 0000 0001 2171 1133, GRID grid.4868.2, Barts and the London School of Medicine and Dentistry, ; Whitechapel, London, E1 2AD UK

[2 ]ISNI 0000 0001 0738 5466, GRID grid.416041.6, Royal London Hospital, Barts Health NHS Trust, ; Whitechapel, London, E1 1BB UK

Author information

Louis Boyce http://orcid.org/0000-0002-7935-6434

Article

Publisher ID: 3127

DOI: 10.1007/s00402-019-03127-5

PMC ID: 6420900

PubMed ID: 30778723

SO-VID: 716dc60b-bfd7-40b4-87ab-a019d7f11765

License:

OpenAccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 20 June 2018

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ScienceOpen disciplines: Orthopedics

Keywords: total knee arthroplasty,tka,total knee replacement,tkr,morbid obesity,obesity,non-obese,revision rate,knee society objective scores,ksos,knee society functional scores,ksfs,complications,complication rates,infection,infection rates,prosthetic infection,superficial wound infection,wound healing problems,wound healing delay,quality of life,functional outcome

Data availability:

ScienceOpen disciplines: Orthopedics

Keywords: total knee arthroplasty, tka, total knee replacement, tkr, morbid obesity, obesity, non-obese, revision rate, knee society objective scores, ksos, knee society functional scores, ksfs, complications, complication rates, infection, infection rates, prosthetic infection, superficial wound infection, wound healing problems, wound healing delay, quality of life, functional outcome

The outcomes of total knee arthroplasty in morbidly obese patients: a systematic review of the literature

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Abstract

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Conclusions

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Orthopedics

Most cited references 35

The influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review.

Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates.

Obesity decreases perioperative tissue oxygenation.

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