Year : 2019 | Volume
: 2 | Issue : 1 | Page : 50--53
The Surprising Effect of Body Mass Index on Elective Orthopedic Surgeries
David T Burke1, Regina B Bell1, Daniel P Burke2,
1 Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
2 Department of Biology, Georgia State University, Atlanta, Georgia, USA
Dr. David T Burke
Department of Rehabilitation Medicine, Emory University School of Medicine, 12 Executive Park Ne, Atlanta 30329, Georgia
Elective orthopedic surgeries are often deferred or declined due to concern about the patient's elevated body mass index (BMI). The study team conducted a literature review of studies focusing on the relationship between BMI and outcomes of elective orthopedic surgical procedures. The literature review found that overweight and obese patients have similar gains in function and pain reduction as do patients with normal weight, with adverse perioperative outcomes more evident in the higher levels of obesity. These data suggest a need to review the current policies concerning surgical eligibility based on BMI. These data suggest that restrictions of surgical procedures based on BMI may be too restrictive and should be revised based on the current literature.
|How to cite this article:|
Burke DT, Bell RB, Burke DP. The Surprising Effect of Body Mass Index on Elective Orthopedic Surgeries.J Int Soc Phys Rehabil Med 2019;2:50-53
|How to cite this URL:|
Burke DT, Bell RB, Burke DP. The Surprising Effect of Body Mass Index on Elective Orthopedic Surgeries. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2023 Feb 4 ];2:50-53
Available from: https://www.jisprm.org/text.asp?2019/2/1/50/254173
According to the World Health Organization, overweight and obesity has a prevalence of 1.9 billion and an annual mortality of 3.4 million adults., The current body mass index (BMI) categories in the United States (US) were established in 1998 when the National Institute of Health lowered the overweight BMI threshold from 28 to 25 kg/m2 to be consistent with international recommendations. BMI categories are calculated as the weight in kilograms divided by height in centimeters squared (kg/m2). The categories include: <18.5 kg/m2 (underweight), 18.5–24.9 kg/m2 (normal weight), 25.0–29.9 kg/m2 (overweight), 30–34.9 kg/m2 (obese Class I), 35–39.9 kg/m2 (obese Class II), and 40 kg/m2 or greater (obese Class III). In the US, the Centers for Disease Control and Prevention estimates that two-thirds of the population are now overweight and/or obese. Given the significant disease burden and implications of obesity it is important, when advising about surgical options, to separate the long-term medical implications of obesity from the short-term and long-term surgical outcomes of patients who choose elective surgical procedures.
For this article, we focused on patients who seek advice concerning elective orthopedic procedures. To allow for a better patient-centric decision process, we focus on medical, perioperative, and long-term surgical outcome data as well as data reflecting preconceptions within the medical community and within the society at large which may influence the decision process.
Studies in the US have demonstrated that individuals with BMI in the obese categories are often viewed negatively by others., Andreyeva et al., in a study of discrimination based on weight in the US, found that the prevalence of this discrimination has risen by 66% in 10 years, and it is now at a rate comparable to that of racial discrimination. Others have found that patients with elevated BMIs believe that health-care facilities are places where they routinely experience shaming, based on their BMI., The data show that those who are obese perceive that they have experienced a weight bias at their physicians' office and often, as a result, feel that their medical concerns are minimized by their clinicians. Puhl and Heuer found that 68% of obese women reported that they avoid clinical care because of their weight and 83% stated that they felt that they did not receive suitable care based on weight alone.
Research into the attitudes of medical staff has supported this perception.,,,, In a study by Jay et al., 45% of medical providers reported a negative response to obese patients, with 18% feeling uncomfortable during the examination and 66% reporting that they feel that treating patients with obesity is frustrating. In a study by Kennedy et al., practitioners concluded that they could not spend enough time to treat patients in need of weight management and their chronic diseases. This review explores the effects of BMI on the functional outcomes of patients who undergo elective orthopedic procedures of the spine, hip, and knee.
Studies concerning obesity and overall mortality in the general population provide conflicting information. Some have found that, as BMI increases, so does mortality. Others differ. Flegal et al., in a meta-analysis of recent literature, found that while obesity, in total, was associated with increased all-cause mortality, those in the overweight category of BMI 25–30 kg/m2 enjoy a significantly reducedall-cause mortality as compared to those in the normal weight category. It is in this overweight category that almost 40% of adult men and 30% of adult women reside. The same meta-analysis found no increased mortality among those with Class I obesity (BMI of 30–34.9 kg/m2). This pattern was reinforced by a prospective study of 12.8 million Koreans which found that mortality in men aged 18–34 years improved steadily as BMI increased from 23 to 25.9 kg/m2 and also improved steadily for those aged 75–99 years, as BMI increased from 25 to 32.9 kg/m2. The pattern was similar for women.
These data have been challenged by others, but have left us to reconsider the line on the BMI continuum at which to express an urgent need for intervention.
Conventionally, adverse events, complications, and increased costs have been associated with surgeries involving patients in the obese categories. Obesity has been linked to longer operative times, increased blood loss, higher treatment costs, greater risk of mortality, and increased rates of both surgical-site infection and venous thromboembolism. The association between an elevated risk of postoperative complications and obesity may be somewhat dependent on confounding variables within the obese categories. When controlling for these variables, some have concluded that only persons with BMI >40 kg/m2 are at risk for higher rates of complications. The current concern about the weight of patients is now reflected in medical decisions, with some clinicians restricting access to surgery based on BMI. Recently, the United Kingdom (UK) National Health Service (NHS) has begun rejecting applications for hip and knee surgery based on elevated BMIs. In a study of the current practices, one-third of the clinical commissioning groups in England are now denying surgery to patients who are overweight or obese.,, Under the latest recommendations, patients with a BMI of 30 kg/m2 or more will be unable to have elective surgery for a year, unless they are able to lose 10% of their body weight.,,
In the US, the American Academy of Orthopaedic Surgeons (AAOS) released a position statement in 2015 recommending that patients with a BMI over 40 kg/m2 consult with their physicians about weight loss before surgery to make sure that they understand their postoperative rehabilitation requirements and whether or not they would be able to comply. Under the AAOS recommendations, patients are also encouraged to sign a promise letterwhich would commit them to a lifestyle intervention of weight loss with exercise and diet. This admonition suggests that weight reflects an issue of personal responsibility and reinforces the perception expressed by patients that they experience a weight-based bias. This bias has therefore, lead to a hesitation to provide needed surgical intervention, and persists despite mounting evidence that patients with obesity recover well after surgery, when allowed the opportunity.,,,, In fact, the harm caused by restricting surgeries based on weight has been voiced by the UK's Royal College of Surgeons in their report,“Smokers and Overweight Patients: Soft targets for NHS Savings?”
Low back pain (LBP) affects 75%–84% of the population. Due to incapacitation by spine injury and disease, patients often seek medical and/or surgical care for pain relief. The relationship between pain and BMI has been noted in several studies.,,, In a meta-analysis, Shiri et al. found that overweight and obese individuals are at a higher risk of LBP as compared to those in lower weight categories. Smuck et al. found that the risk for LBP was 7.7% in obese Class I increasing to 11.6% for those with BMI categories of obese Class II and III.
Central to the surgical restrictions based on weight are the data suggesting that patients with higher BMI have an increase in the risk of perioperative complications during spinal surgery. Beyond this short perioperative timeframe, a growing number of studies have found that the surgical outcomes of many individuals in the obese categories are similar to those of patients with BMI within the normal range. Brennan et al. in a study of patients undergoing lumbar discectomy found surgical outcomes for obese patients comparable to those of normal weight patients. Park et al. did not find any increased risk for perioperative complications in higher BMI patients undergoing minimally invasive spinal surgery. Similar findings were expressed by Peng et al. in a study regarding perioperative outcomes with obese patients undergoing anterior lumbar surgery. Chotai et al. found that obese patients undergoing elective anterior cervical discectomy and fusion surgery for degenerative cervical pathology had substantial improvements, not only with pain, but with disability and quality of life.
The study also found that the surgery was economical, noting only a slight increase in cost as compared to the costs for normal weight patients. Once again, a patient-centric process would emphasize both the short-term risks of complications as well as the long-term benefits of the surgery so as to offer an informed consent that would allow the patient to accept the short-term risks and gain the long-term outcomes.
As an indirect measure of severe osteoarthritis (OA), joint replacement may be thought of as “terminal” OA. Some large studies demonstrate that BMI, weight, and other measures of adiposity have a linear relationship with this risk. This relationship may not be as clear as merely BMI, as some subsets of adiposity measures may be of greater importance. Patients with BMIs within the obesity categories have been found to be at greater risk of perioperative complications, with some finding an increased risk of premature joint failure and revision. The final functional outcome of total knee arthroplasty (TKA) has been found to be worse in the obese than the nonobese group. However, these patients often begin at a worse functional level, with the absolute improvements found to be similar in both groups. To put this in context, Collins et al. found that after a TKA, patients in the obese categories had greater improvement in pain than those in the lower BMI categories. They also found that improvements in function relative to baseline were greater among the obese than in the lower weight patients. Therefore at 3 months, the patients in the obese category demonstrated greater improvement than their lighter counterparts, suggesting greater potential gains.
These findings have been echoed in the writings of others. Li et al. conducted a study on functional gain and obese patients after total joint replacement. Even those in the higher ranges of obesity have reported reduced pain and significant functional gains. Vincent et al. reported similar findings after total hip arthroplasty. Though these surgeries have a higher cost and risk, without these surgeries, the overweight/obese patients become less mobile and experience increasing pain.,,
This literature review identifies a hesitation to perform elective surgical procedures, which seems to emanate from or coincide with a societal prejudice against those who are overweight. This seems to reinforce a perception by the patients that this prejudice extends to their medical care. We demonstrate that these perceptions are substantiated in part by studies of attitudes of clinicians toward their obese patients, with data further demonstrating that patients, while likely to have significant benefits from surgery may encounter resistance or rejection by the physicians whose care they seek.
As John Adams is famous for saying, “facts are stubborn things.” The “facts” contained in this literature review may provide a database to resist a decision process that is infected with a bias based on BMI. We need to better inform the clinical decisions regarding patients seeking elective orthopedic procedures. As the data reflect a short perioperative increase in adverse events, but also a significant improvement in pain and function among those who receive these surgeries, these should be presented to the patient to allow for an informed decision process.
While obesity and health-related behaviors associated with obesity have long-term medical consequences, this paper narrows the focus to inform the decision process for elective surgery for disabling orthopedic issues. We believe that this summary outlines the rationale for rethinking a policy of deferring elective orthopedic procedures for those with a BMI higher than 25 kg/m2 and allowing a greater number of patients to receive these interventions. As we vow “primum non nocere,” we should be vigilant of the harm of omission and rethink our eligibility parameters from a patient-centric view.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
|1||World Health Organization. Obesity and Overweight. Fact Sheet. World Health Organization. February, 2018. Available from: http://www.who.int/mediacentre/factsheets/fs311/en/.|
|2||World Health Organization. Global Health Observatory (GHO) Data, Obesity. Available from: http://www.euro.who.int/en/health-topics/disease-prevention/nutrition/a-healthy-lifestyle/body-mass-index-bmi.|
|3||Nuttall FQ. Body mass index: Obesity, BMI, and health: A critical review. Nutr Today 2015;50:117-28.|
|4||World Health Organization. BMI Classification. Available from: http://www.apps.who.int/bmi/index.jsp?introPage=intro_3.html.|
|5||Centers for Disease Control and Prevention. National Center for Health Statistics. Obesity and Overweight. Available from: https://www.cdc.gov/nchs/fastats/obesity-overweight.htm. [Last updated on 2017 May 03].|
|6||Puhl RM, Heuer CA. Obesity stigma: Important considerations for public health. Am J Public Health 2010;100:1019-28.|
|7||Andreyeva T, Puhl RM, Brownell KD. Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006. Obesity (Silver Spring) 2008;16:1129-34.|
|8||Puhl RM, King KM. Weight discrimination and bullying. Best Pract Res Clin Endocrinol Metab 2013;27:117-27.|
|9||Jay M, Kalet A, Ark T, McMacken M, Messito MJ, Richter R, et al. Physicians' attitudes about obesity and their associations with competency and specialty: A cross-sectional study. BMC Health Serv Res 2009;9:106.|
|10||Kennedy BM, Kennedy KB, Sarpong DF, Katzmarzyk PT. Perceptions of obesity treatment options among healthcare providers and low-income primary care patients. Ochsner J 2016;16:158-65.|
|11||Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis. JAMA 2013;309:71-82.|
|12||Yi SW, Ohrr H, Shin SA, Yi JJ. Sex-age-specific association of body mass index with all-cause mortality among 12.8 million Korean adults: A prospective cohort study. Int J Epidemiol 2015;44:1696-705.|
|13||Global BMI Mortality Collaboration, Di Angelantonio E, Bhupathiraju ShN, Wormser D, Gao P, Kaptoge S, et al. Body-mass index and all-cause mortality: Individual-participant-data meta-analysis of 239 prospective studies in four continents. Lancet 2016;388:776-86.|
|14||Jackson KL 2nd, Devine JG. The effects of obesity on spine surgery: A systematic review of the literature. Global Spine J 2016;6:394-400.|
|15||The Royal College of Surgeons. More Than one in Three Areas of England Restrict Surgery for Smokers and Overweight Patients. The Royal College of Surgeons; 22 April, 2016. Available from: https://www.rcseng.ac.uk/news-and-events/media- centre/press-releases/more-than-one-in-three-areas-of-england-restrict-surgery-for-smokers-and- overweight-patients/.|
|16||The Royal College of Surgeons of England. Smokers and Overweight Patients: Soft targets for NHS Savings?; Published April, 2016. Available from: https://www.rcseng.ac.uk/-/media/files/rcs/library-and-publications/non-journal-publications/smokers-and-overweight-patients--soft-targets-for-nhs-savings.pdf.|
|17||Iacobucci G. Smokers and overweight patients are denied surgery, royal college finds. BMJ 2016;353:i2335.|
|18||American Academy of Orthopaedic Surgeons. Position Statement 1184: The Impact of Obesity on Bone and Joint Health; March, 2015. Available from: https://www.aaos.org/About/Statements/Position/.|
|19||Burke D, Spinelli J, Hoaglin H. The effect of body mass index on the outcome of rehabilitation. Poster Session Presented at: Annual Meeting of the Association of Academic Physiatrists. San Juan, PR; 2007.|
|20||Jain NB, Burke DT. Association between body mass index and gain in FIM scores. Poster Session Presented at: American Academy of Physical Medicine and Rehabilitation. San Diego, CA; 2008.|
|21||Burke DT, Castellan CL, Jain NB. BMI influence on rehabilitation of amputations. Poster Session Presented at: Annual Meeting of the Association of Academic Physiatrists. Las Vegas, NV; 2012.|
|22||Thiese MS, Hegmann KT, Wood EM, Garg A, Moore JS, Kapellusch J, et al. Prevalence of low back pain by anatomic location and intensity in an occupational population. BMC Musculoskelet Disord 2014;15:283.|
|23||Abraham P, Rennert RC, Martin JR, Ciacci J, Taylor W, Resnick D, et al. The role of surgery for treatment of low back pain: Insights from the randomized controlled spine patient outcomes research trials. Surg Neurol Int 2016;7:38.|
|24||Chou L, Brady SR, Urquhart DM, Teichtahl AJ, Cicuttini FM, Pasco JA, et al. The association between obesity and low back pain and disability is affected by mood disorders: A population-based, cross-sectional study of men. Medicine (Baltimore) 2016;95:e3367.|
|25||Hitt HC, McMillen RC, Thornton-Neaves T, Koch K, Cosby AG. Comorbidity of obesity and pain in a general population: Results from the southern pain prevalence study. J Pain 2007;8:430-6.|
|26||Wright LJ, Schur E, Noonan C, Ahumada S, Buchwald D, Afari N, et al. Chronic pain, overweight, and obesity: Findings from a community-based twin registry. J Pain 2010;11:628-35.|
|27||Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between obesity and low back pain: A meta-analysis. Am J Epidemiol 2010;171:135-54.|
|28||Smuck M, Kao MC, Brar N, Martinez-Ith A, Choi J, Tomkins-Lane CC, et al. Does physical activity influence the relationship between low back pain and obesity? Spine J 2014;14:209-16.|
|29||Buerba RA, Fu MC, Gruskay JA, Long WD 3rd, Grauer JN. Obese class III patients at significantly greater risk of multiple complications after lumbar surgery: An analysis of 10,387 patients in the ACS NSQIP database. Spine J 2014;14:2008-18.|
|30||Brennan PM, Loan JJM, Watson N, Bhatt PM, Bodkin PA. Pre-operative obesity does not predict poorer symptom control and quality of life after lumbar disc surgery. Br J Neurosurg 2017;31:682-7.|
|31||Park P, Upadhyaya C, Garton HJ, Foley KT. The impact of minimally invasive spine surgery on perioperative complications in overweight or obese patients. Neurosurgery 2008;62:693-9.|
|32||Peng CW, Bendo JA, Goldstein JA, Nalbandian MM. Perioperative outcomes of anterior lumbar surgery in obese versus non-obese patients. Spine J 2009;9:715-20.|
|33||Chotai S, Sielatycki JA, Parker SL, Sivaganesan A, Kay HL, Stonko DP, et al. Effect of obesity on cost per quality-adjusted life years gained following anterior cervical discectomy and fusion in elective degenerative pathology. Spine J 2016;16:1342-50.|
|34||Wang Y, Simpson JA, Wluka AE, Teichtahl AJ, English DR, Giles GG, et al. Relationship between body adiposity measures and risk of primary knee and hip replacement for osteoarthritis: A prospective cohort study. Arthritis Res Ther 2009;11:R31.|
|35||Collins RA, Walmsley PJ, Amin AK, Brenkel IJ, Clayton RA. Does obesity influence clinical outcome at nine years following total knee replacement? J Bone Joint Surg Br 2012;94:1351-5.|
|36||Li W, Ayers DC, Lewis CG, Bowen TR, Allison JJ, Franklin PD, et al. Functional gain and pain relief after total joint replacement according to obesity status. J Bone Joint Surg Am 2017;99:1183-9.|
|37||Vincent HK, Weng JP, Vincent KR. Effect of obesity on inpatient rehabilitation outcomes after total hip arthroplasty. Obesity (Silver Spring) 2007;15:522-30.|
|38||Wallace G, Judge A, Prieto-Alhambra D, de Vries F, Arden NK, Cooper C, et al. The effect of body mass index on the risk of post-operative complications during the 6 months following total hip replacement or total knee replacement surgery. Osteoarthritis Cartilage 2014;22:918-27.|
|39||Kremers HM, Visscher SL, Kremers WK, Naessens JM, Lewallen DG. The effect of obesity on direct medical costs in total knee arthroplasty. J Bone Joint Surg Am 2014;96:718-24.|
|40||Vincent HK, Horodyski M, Gearen P, Vlasak R, Seay AN, Conrad BP, et al. Obesity and long term functional outcomes following elective total hip replacement. J Orthop Surg Res 2012;7:16.|