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Commentary and Perspective

Surgical Decision-Making: The Province of the Patient or the Surgeon?

Commentary on an article by Nicholas J. Giori, MD, PhD, et al.: “Risk Reduction Compared with Access to Care: Quantifying the Trade-Off of Enforcing a Body Mass Index Eligibility Criterion for Joint Replacement”

Shaw, James A. MD

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The Journal of Bone and Joint Surgery: April 4, 2018 - Volume 100 - Issue 7 - p e45
doi: 10.2106/JBJS.17.01175
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Dr. Giori et al. have written an interesting, informative, and provocative article, one sure to engender heated discussion for years to come. The authors acknowledge and thoroughly reference the fact that morbid obesity increases the risks of serious complications following total joint arthroplasty. However, with quoted references stating that 37% of the population in the United States is considered to be obese and 7.7% is considered to be morbidly obese, and with obesity having a documented causal relationship to osteoarthritis, they contend, with rigorous analysis, that many patients would be denied the life-changing benefits of total joint arthroplasty if arbitrary body mass index (BMI) criteria are used as a decision-making criterion defining eligibility for total joint arthroplasty.

The authors’ analysis documents that avoidance of complications using a BMI of 30 kg/m2 as a cutoff criterion for a surgical procedure is no better than a coin flip. If a BMI of ≥40 kg/m2 is used, the number of patients denied beneficial care is 14 times larger than those spared a complication. That being the case, in the original draft of the article, the authors implied that patients should have the freedom of surgical choice, independent of the surgeon’s concerns or the potential costs to society of 1 in 14 patients in this group having a serious complication.

Both clinical manuscript reviewers countered that surgeons have rights as well. Bearing the emotional, time-consuming, and financial burden of a serious complication following total joint arthroplasty is a factor that only a surgeon, who has had a patient with a serious postoperative complication, can appreciate. To quote a sage comment made by Dr. Bob Booth many years ago: “There are two horrible complications following total joint arthroplasty. One is death and the other is deep infection. Of the two, infection is probably the worst as the patient wishes he or she was dead, but so does the surgeon!”

In response to the reviewers’ critiques, the authors acknowledge the surgeon’s rightful role in the decision-making process in the published version of the article. According to the authors, “Surgeons who perform operations on morbidly obese patients also assume responsibility and risk. A decision to operate is a commitment to care for complications. Complications are emotionally draining, require additional time and resources, and can be financially harmful to the surgeon’s practice.” In addition, the authors state that they believe that: “It is unreasonable to interfere with the patient and physician relationship by administratively setting rigid surgical eligibility standards for joint replacement as they can have broad and poorly understood consequences.”

All arthroplasty surgeons must deal with the pall of surgical complications on a daily basis. A major distinction from other surgical procedures is that total joint arthroplasty engenders significant risks and is, at the same time, a semi-elective operation, complicating the decision-making process. Every patient with a good result is delighted. Those few with serious complications wish that they had never undergone the operation. So surgeons must ask themselves how many patients they are willing to cause harm (on a statistical basis) to benefit the remainder. A serious complication in 1 of 14 in the ≥40-kg/m2 BMI group strikes me as an unacceptable risk-to-benefit ratio. Obviously, others may disagree, with no right or wrong opinion.

Many patients will state that they cannot live with a hip or knee in its current arthritic state and would rather die and/or risk infection or other complications than continue life in its present state of pain and disability. The problem with that declaration is that most patients and family members, in my experience, change their minds when faced with death or a major complication. Anger, depression, and/or incrimination against the surgeon frequently follow major complications.

The complexity of the surgical decision-making process remains a conundrum with good arguments that both the patient and the surgeon should hold preemptive responsibility. This article does not resolve the debate, but provides data for informed discussion regarding the process of shared decision-making.

Disclosure: There was no external funding for this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (

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