Tag Archives: hip surgical outcomes

Should There Be Strict BMI Cutoffs for TKA and THA?

happy senior couple hiking on the mountainDr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more.

Recently we posted a blog about candidacy for and outcomes of Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) in morbidly obese patients who underwent pre-operative weight loss. Operating on obese patients for TKA and THA continues to be a hot button topic of risk versus reward in surgical outcomes.

Two well-respected orthopedic authorities, recently faced off to have a deeper conversation about whether or not orthopedic surgeons should have strict BMI cutoffs for performing primary TKA or THA. Benjamin F. Ricciardi, MD engaged Thomas K. Fehring, MD, from OrthoCarolina and Nicholas Giori, MD and PhD, a Stanford University professor, to face off. Highlights are summarized below.

Q: To what degree does the evidence support a strict BMI cutoff to determine eligibility for primary TKA and THA?

Dr. Fehring noted many Americans (35%) are obese and the association between patients with a BMI above 40 and surgical complications/infection is irrefutable. He recommends looking at big data such as Medicare or Veterans Affairs, meta-analysis, and position statements by specialty medical societies. All findings to date underscore the need to have a strict cutoff, but Dr. Fehring noted it’s important to develop weight loss strategies for patients prior to arthroplasty. 

Dr. Giori agreed that obesity is undeniably related to complications, but BMI is a weak risk factor compared to others that are commonly accepted (such as heart and metabolic disorders).

Q: Given the expansion of strict BMI cutoffs at the administrative level, how should safety (non-maleficence) be balanced against access to care?

Dr. Giori said that while BMI cutoffs are well-intended, the ones currently used have the effect of arbitrarily rationing care without medical justification. Also, he feels it disproportionately affects minorities, women and patients in low socio-economic classes. In his opinion, the decision should be based on joint decision making between the doctor and the patient. Risk adjustments in payment models (for doctors’ compensation) would help in the future.

Dr. Fehring agreed with many of the points, but at a certain point the risk outweighs the benefit, and attempting to operate on all patients regardless of BMI becomes dangerous. Keeping his “do no harm” obligation in mind, Dr. Fehring stated a BMI cutoff of 40 as a reasonable goal for patient safety.

Q: If a patient with morbid obesity is to undergo arthroplasty, what steps should be taken before surgery to make hip or knee arthroplasty safer?

Dr. Fehring recommended the patient be in the best possible health they can be prior to elective surgery to avoid complications. An optimization program, factoring in body weight, blood glucose control, serum albumin, and smoking status are part of his clinic’s protocol; patients get tools to meet and stick to set goals before getting surgery. It’s not just about treating the knee or hip; it’s about treating the whole patient as well, he said.

Dr. Giori recognized that optimization programs can help and his clinic also offers one, but the best that can be done regarding obesity is encouragement and education, and referring the patient to a structured weight-reduction program. On the flipside, the patient should do his or her best to lose weight to get below a given BMI threshold. From there, doctor and patient can create a shared decision-making plan that may or may not involve surgery.

If you’d like to discuss weight concerns prior to your total knee or hip replacement surgery, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

After One Joint Wears Out, Will More Go?

Hip, back and spinal problems in young ages.Here’s a question I’m often asked by patients: “If one of my joints has worn out, how likely are the others to go?” A recent publication from the Osteoarthritis Initiative (OAI) lends some insights into this question. The study, found in the Aug. 12, 2019 issue of Clinical Orthopaedics and Related Research, is the first of its kind. The likelihood of undergoing a 2nd Arthroplasty (Joint replacement) after hip or knee replacement had not previously been evaluated.

The authors prospectively asked two questions: “What is the likelihood of second Total Knee Arthroplasty (TKA) or Total Hip Arthroplasty (THA) after primary TKA or THA?” and “What risk factors are associated with undergoing addition joint replacement. The study identified 332 patients who underwent primary TKA and another 132 who underwent THA across five OAI-participating centers in the U.S., who hadn’t previously had a THA or TKA. The patients were followed for 8 years after their primary joint replacement.

  • The incidence of contralateral (opposite Knee) TKA after primary TKA was 40%
  • The incidence of THA after any TKA was 13%
  • The incidence of contralateral (opposite) THA after primary THA was 8%
  • The incidence of any TKA after primary THA was 32%

As for the second question in the study: Risk factors for undergoing contralateral TKA were younger age and a loss of medial joint space with a varus angulation, or bow leg deformity.

The conclusion is clear: Patients who underwent TKA or THA for osteoarthritis had a relatively high rate of subsequent joint arthroplasty. There’s no question that osteoarthritis is common and debilitating, and often it affects more than one large, weight-bearing joint.

If you need a joint replacement or want to learn more about the procedure, hip or knee replacement surgical outcomes, recovery and quality-of-life prognosis, please contact our office. We’ll help you return to your healthy, pain-free lifestyle. Dr. Stickney, a Kirkland orthopedic surgeon, is a knee and hip expert specializing in joint replacement surgery.

The Risk of Needing a Second Surgery

 

Shot of a wife comforting her husband lying in a hospital bedFor many patients, undergoing a total hip or knee arthroplasty may seem like the solution to joint pain and the opportunity to return to a more mobile, active lifestyle. However, the possibility of facing a secondary surgery may seem frustrating or daunting. Though the number of total hip and knee arthroplasties has risen in recent years, the incidence and prevalence of secondary surgeries isn’t well understood.

A new study from the National Center for Biotechnology Information sought to examine rates of incidence. First, researchers examined groups that either had total hip arthroplasty (1,933 subjects) or total knee arthroplasty (2,139 subjects) between 1969 and 2008.

Following-up after an average of 12 years from initial total hip arthroplasty, the researchers found that if a patient had a hip replacement on one sider, there was a 29% chance he or she would require a hip replacement on the other side. Those who underwent primary surgery at a younger age had a significantly high incidence of a follow-up operation.

For the total knee arthroplasties, the researchers followed up after an average of 11 years. They found that those who had a knee replacement on one side had a 45% chance of requiring a knee replacement on the other side within 20 years. However, only 3% of patients required a hip replacement on the opposite side of the body, and just 2% required a hip replacement on the same side of the body. Here, older age significantly contributed to the necessity of a second surgery.

These findings reveal that patients facing either a total hip or total knee arthroplasty have a 29 to 45% chance of needing secondary surgery on the opposite side of the body within 20 years of the original surgery. Struggling with joint pain?

Dr. Stickney, a Kirkland orthopedic surgeon, can help you find the surgical or nonsurgical that will reduce discomfort and help you return to a healthy lifestyle. Contact his office today.

Does Timing for Total Joint Surgery Matter?

TJA-importanceWhile choosing whether or not to get total joint arthroplasty (TJA) can be a difficult and daunting decision, new research shows that delaying it may have a negative impact on postoperative outcomes. Carlos J. Lavernia, MD, who helmed a study evaluating pre- and postoperative functioning, presented his findings at the American Association of Hip and Knee Surgeons’ (AAHKS) annual meeting.

Previously, Dr. Lavernia had studied TJA patients and found those with lower preoperative functioning had worse short-term self-reported outcomes after surgery than their higher preoperative functioning peers. Interested in examining the long-term impacts, Dr. Lavernia and his team looked at 105 patients from the original group and split them into those who were severely functionally impaired versus those who were functionally impaired. The demographics for both groups were very similar, though the first was 40% female and the latter was 73.8% female.

The patients had an average age of 65 years and 54 had total hip arthroplasties while 51 had total knee arthroplasties. The mean follow-up period for all patients was 11.2 years, 13 had revision surgery, and 43 passed away. However, there did not seem to be significant differences in revision or mortality statistics between the severely functionally impaired and functionally impaired groups.

The research team calculated scores using the Western Ontario and McMaster Osteoarthritis Index, Short Form 36, and the Quality of Well Being Scale both pre- and post-operation. They found that while all scores improved after surgery, those who had lower preoperative scores continued to have worse hip and knee surgical outcomes after the arthroplasty.

“We found that those who allowed their function to deteriorate significantly before undergoing TJA did not fully ‘catch up’ to patients who underwent surgery at an earlier disease stage,” Dr. Lavernia said.

This research emphasizes the importance of undergoing TJA earlier rather than later and treating the disease as early in its course as possible. Consulting an orthopedic surgeon can help you determine if surgery may be the appropriate intervention.

Concerned about joint pain? Wondering if orthopedic surgery is the right choice for you? Curious about hip or knee postoperative rehabilitation? Dr. Stickney is a Kirkland orthopedic surgeon who can help you return to an active, healthy lifestyle. Contact his office today at 425.823.4000 to learn about the surgical and nonsurgical options best for you.