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Laperche, J., Feinn, R., Myrick, K., & Halawi, M. J. (2022). Obesity and total joint arthroplasty: Does weight loss in the preoperative period improve perioperative outcomes?. Arthroplasty (London, England), 4(1), 47. https://doi.org/10.1186/s42836-022-00149-0

Retrospective study

Background: The obese population is more likely to develop degenerative joint disease requiring total joint arthroplasty (TJA) and also experience increased rates of adverse post-surgical outcomes. This study assessed whether a quantifiable weight loss prior to TJA had any impact on perioperative and 30-day outcomes in obese patients.

Methods: Using the American College of Surgeons-National Surgical Quality Improvement Program database, obese patients who underwent total hip or total knee arthroplasty and lost at least 10% of their total body weight prior to surgery were identified and matched to other obese individuals undergoing the same procedures without weight loss. Perioperative outcomes, including operative time, length of stay, discharge destination, or 30-day adverse events, including complications, re-admissions, re-operations, and mortality, were then compared using conditional Logistic regression analysis.

Results: Analysis showed no difference between the two groups in terms of operative time, length of stay, discharge destination, or 30-day adverse events, including complications, re-admissions, re-operations, and mortality.

Conclusion: The results of this study suggest that weight loss alone in the preoperative period may not be sufficient to mitigate the efects of obesity on immediate post-TJA outcomes.

• Retrospective cohort study of obese (BMI ≥  30) individuals undergoing total knee and total hip procedures from 2010-2018.
• Those in the study considered the weight loss group had 10% reduction in total body weight in the 6 months prior to surgical date.
• Outcomes measured included length of hospital stay (related to complications), discharge to rehab or SNF, 30-day complications, re-admissions, re-operations, and mortality. (Many complication factors were assessed which was one of my outcomes being evaluated).
• Results showed that weight loss alone did not have a significant impact on reducing complications. (no improvement in operative time, LOS, non-home discharge, and 30-day adverse events).

I chose this article because I felt that it directly helped me answer aspects of my PICO question. It included the PICO elements I was looking to evaluate (obese adults scheduled for total knee surgery, preoperative weight loss, a non-weight loss group, and complications). The study also evaluated total hip procedure patients which wasn’t directly associated to my study but made me curious in other potential PICO questions to see if there was a difference in the effects of preoperative weight loss on TKA patients and THA patients (plan on pursuing this question in future PICO’s). Although the study didn’t directly answer the functional aspect of my outcomes, I felt that I could answer that in future articles and felt that this was a great article to help answer my research.

Lawrence, K. W., Sobba, W., Rajahraman, V., Schwarzkopf, R., & Rozell, J. C. (2023). Does body mass index influence improvement in patient reported outcomes following total knee arthroplasty? A retrospective analysis of 3918 cases. Knee surgery & related research, 35(1), 21. https://doi.org/10.1186/s43019-023-00195-1

Retrospective case review

Purpose: The study aimed to determine whether body mass index (BMI) classification for patients undergoing total knee arthroplasty (TKA) is associated with differences in mean patient reported outcome measure (PROM) score improvements across multiple domains-including pain, functional status, mental health, and global physical health. We hypothesized that patients with larger BMIs would have worse preoperative and postoperative PROM scores, though improvements in scores would be comparable between groups.

Materials and Methods: Patients undergoing primary TKA from 2018 to 2021 were retrospectively reviewed and stratified into four groups: Normal Weight; 18.5-25 kg/m², Overweight; 25.01-30 kg/m², Obese; 30.01-40 kg/m², and Morbidly Obese > 40 kg/m². Preoperative, postoperative, and pre/post-changes (Δ) in knee injury and osteoarthritis, joint replacement (KOOS, JR) and Patient-Reported Outcome Measurement Information System (PROMIS) measures of pain intensity, pain interference, physical function, mobility, mental health, and physical health were compared. Multivariate linear regression was used to assess for confounding comorbid conditions.

Results: In univariate analysis, patients with larger BMIs had worse scores for KOOS, JR and all PROMIS metrics preoperatively. Postoperatively, scores for KOOS, JR and PROMIS pain interference, mobility, and physical health were statistically worse in higher BMI groups, though differences were not clinically significant. Morbidly obese patients achieved greater pre/post-Δ improvements in KOOS, JR and global physical health scores. Multivariate regression analysis showed high BMI was independently associated with greater pre/post-Δ improvements in KOOS, JR and global health scores.

Conclusion: Obese patients report worse preoperative scores for function and health, but greater pre/post-Δ improvements in KOOS, JR and physical health scores following TKA. Quality of life benefits of TKA in obese patients should be a factor when assessing surgical candidacy.

•  Large retrospective analysis of 3,918 patients (previous PICOS I struggled with finding studies with a large data set)
• Evaluated pre total knee arthroplasty patients belonging to 4 groups from 2018-2021 (: Normal Weight; 18.5–25 kg/m2 , Overweight; 25.01–30 kg/m2 , Obese; 30.01–40 kg/ m2 , and Morbidly Obese>40 kg/m2)
• Methods of evaluation included preoperative, postoperative, and pre/post-changes in knee pain intensity, pain interference, physical function, mobility, mental health, and physical health (bold directly related to functional outcomes),
• Article doesn’t directly discuss weight loss in obese individuals but evaluates individuals of different BMI’s and their functional outcomes.
• Obese patients reported worse preoperative scores for function and health, but greater pre/post changes in above methods of measurement

I chose this article because it was a USA study that included a large evaluation group of 3,918 patients. Although the article didn’t discuss weight loss, it evaluated patients of 4 different groups based on their BMI. This included obese patients and patients who were not obese, so incorporating this article I was still able to evaluate the functional outcomes of patients undergoing TKA. The article looked at results discussing function and pain (complication) which are both components of my PICO elements. Overall, although it wasn’t identical to the article I was hoping to find as it didn’t incorporate the same patient losing weight, it helped answer my PICO question and included all aspects of my PICO elements (obese patients scheduled for TKA (non weight loss group), non obese patients scheduled for TKA (weight loss group), and evaluation of function.  It helped research components of my PICO that the first article I chose didn’t.

Liljensøe, A., Laursen, J. O., Bliddal, H., Søballe, K., & Mechlenburg, I. (2021). Weight Loss Intervention Before Total Knee Replacement: A 12-Month Randomized Controlled Trial. Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society, 110(1), 3–12. https://doi.org/10.1177/1457496919883812

Randomized Control Trial

Background and aims: Obesity is an increasing problem in patients after total knee replacement. The aim of this study was to investigate whether a weight loss intervention before primary total knee replacement would improve quality of life, knee function, mobility, and body composition 1 year after surgery.

Material and methods: Patients scheduled for total knee replacement due to osteoarthritis of the knee and obesity were randomized to a control group receiving standard care or to an intervention group receiving 8-week low-energy diet before total knee replacement. Patient-reported quality of life, 6-Min Walk Test, and body composition by dual-energy X-ray absorptiometry were assessed before intervention for the diet group, and within 1 week preoperatively for both groups, and the changes in outcome from baseline to 1 year after total knee replacement were compared between groups. The number of participants was lower than planned, which might introduce a type-2 error and underestimate the trend for a better outcome after weight loss.

Results: The analyses are based on a total of 76 patients, 38 in each group. This study showed major improvement in both study groups in quality of life and knee function, though no statistically significant differences between the groups were observed 1 year after total knee replacement. The average weight loss after 8-week preoperative intervention was 10.7 kg and consisted of a 6.7 kg reduction in fat mass. One year after total knee replacement, the participants in the diet group managed to maintain the weight reduction, whereas there was no change in the control group.

Conclusion: The results suggest that it is feasible and safe to implement an intensive weight loss program shortly before total knee replacement. The preoperative intervention resulted in a 10% body weight loss, improved body composition, lower cardiovascular risk factors, and sustained s-leptin.

• Randomized control trial of 76 patients with a BMI ≥ 30 undergoing TKA (38 in group receiving standard care) (38 in group receiving 8-week-low energy diet prior to surgical date).
• Factors measured included quality of life, function, mobility, complications, and body compensation at 1 year post surgery.
• Results showed considerable improvement in both the groups in quality of life, knee function, limitation of complications and mobility. No significant differences were found between both groups.

Although it is a foreign article, it was directly associated with my PICO question and helped me with my research. I reviewed various search tools and after trying to find a USA based article that was most relevant to my research I decided this was most appropriate even though it was foreign. It was a randomized control trial which is a study that limits any bias. I had not included any randomized control trails in my previous studies as they were both retrospective studies. I thought it was well organized and a creative way to examine the research question by creating a low energy diet. All my PICO search elements were examined (obese patients, preoperative weight loss, standard care, and complications and function).