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Preoperative Weight Loss for Morbidly Obese Patients Undergoing Total Knee Arthroplasty

Determining the Necessary Amount

Keeney, Benjamin J. PhD1,2,3; Austin, Daniel C. MD, MS2; Jevsevar, David S. MD, MBA2,3

doi: 10.2106/JBJS.18.01136
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Background: Many surgeons require or request weight loss among morbidly obese patients (those with a body mass index [BMI] of ≥40 kg/m2) before undergoing total knee arthroplasty. We sought to determine how much weight reduction was necessary to improve operative time, length of stay, discharge to a facility, and physical function improvement.

Methods: Using a retrospective review of cohort data that were prospectively collected from 2011 to 2016 at 1 tertiary institution, we identified 203 patients who were morbidly obese at least 90 days before the surgical procedure and had their BMI measured again at the immediate preoperative visit. All heights and weights were clinically measured. We used logistic and linear regression models that adjusted for preoperative age, sex, year of the surgical procedure, bilateral status, physical function (Patient-Reported Outcomes Measurement Information System [PROMIS]-10 physical component score [PCS]), mental function (PROMIS-10 mental component score [MCS]), and the Charlson Comorbidity Index.

Results: Of the 203 patients in the study, 41% lost at least 5 pounds (2.27 kg) before the surgical procedure, 29% lost at least 10 pounds (4.54 kg), and 14% lost at least 20 pounds (9.07 kg). Among morbidly obese patients, losing 20 pounds before a total knee arthroplasty was associated with lower adjusted odds of discharge to a facility (odds ratio [OR], 0.28 [95% confidence interval (CI), 0.09 to 0.94]; p = 0.039), lower odds of extended length of stay of at least 4 days (OR, 0.24 [95% CI, 0.07 to 0.88]; p = 0.031), and an absolute shorter length of stay (mean difference, −0.87 day [95% CI, −1.39 to −0.36 days]; p = 0.001). There were no differences in operative time or PCS improvement. Losing 5 or 10 pounds was not associated with differences in any outcome.

Conclusions: Losing at least 20 pounds before total knee arthroplasty was associated with shorter length of stay and lower odds of facility discharge for morbidly obese patients, even while most patients remained morbidly or severely obese. Although there were no differences in operative time or physical function improvement, this has considerable implications for patient burden and cost reduction. Patients and providers may want to focus on larger preoperative weight loss targets.

Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

1Berkley Medical Management Solutions, a W.R. Berkley Company, Overland Park, Kansas

2Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

3Department of Orthopaedics, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire

E-mail address for B.J. Keeney: BKeeney@BerkleyMMS.com; Benjamin.J.Keeney@Hitchcock.org; Benjamin.J.Keeney@Dartmouth.edu; Benjamin.Keeney@gmail.com

E-mail address for D.C. Austin: Daniel.C.Austin@Hitchcock.org

E-mail address for D.S. Jevsevar: David.S.Jevsevar@Hitchcock.org; David.S.Jevsevar@Dartmouth.edu

Investigation performed at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/F400).

Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated
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