Commentary and Perspective
The increasing body weights of our patients and the growing responsibility to avoid postoperative adverse events have put a new urgency into expanding our knowledge of the impact of comorbidities such obesity on our patients and health-care system. Thirty years ago in my own practice, performing a total hip replacement on a patient with a body mass index (BMI) of >40 kg/m2 was unusual. Higher complication rates were expected and were addressed as necessary. Now even heavier patients are appearing in our clinics, putting more pressure on surgeons and hospitals. The implementation of bundled payment requiring that hospitals cover any postoperative complication or need for readmission within ninety days will further increase these pressures. Not surprisingly, there is concern that patients with comorbidities such as extreme obesity may not be able to obtain care.
Issa et al. present new data about outcomes and complications of super-obese patients undergoing total hip arthroplasty. These data will be helpful in understanding the cost of care and expectations of the patient and health-care professionals. The authors present an excellent retrospective review of forty-five patients (forty-eight hips) with a minimum BMI of 50 kg/m2 who underwent total hip arthroplasty at one of four high-volume joint centers. They compare implant survival, complication rates, Harris hip scores, Short Form-36 (SF-36) scores, and University of California Los Angeles (UCLA) activity scores with a matched control group of patients with a BMI of <30 kg/m2. Patients were followed for four to twelve years, which further contributes to the previous study by Issa et al. on super-obese patients undergoing total hip arthroplasty followed for three years1.
In the current study, Issa et al. report an 8.2% lower implant survival rate in the super-obese patient at a mean time of six years and a 4.5% rate of septic revision. Compared with the non-obese patients, super-obese patients had inferior clinical results, as demonstrated by significantly lower postoperative scores. It is important to note that these results were submitted from experienced surgeons practicing in high-volume joint centers.
Equally important is the documentation that, even from 2001 to 2010, super-obese patients had difficulty finding surgeons who would perform the surgical procedure on them. Although the authors do not tell us why other surgeons would not operate on these patients, bundled payment will likely make access to care even harder for these patients. This article provides needed data that will help us to understand the increased burden of the super-obese patient on our health-care system.
Issa et al. point out that the study was retrospective, although many of the data were accumulated prospectively. The authors also do not discuss the option of delaying the surgical procedure on these patients until and unless they lose weight or undergo a bariatric surgical procedure, which are relevant alternative approaches.
1. Issa K, Wohl H, Naziri Q, McDermott JD, Cherian JJ, Mont MA. Early results of total hip arthroplasty in the super-obese patients. J Long Term Eff Med Implants. 2013;23(4):309-13.