Review Article

Obesity Treatment in Orthopaedic Surgery

Dominic Carreira, MD
J. Weston Robison, MD
Susannah Robison, RDN, LD
ABSTRACT
Angela Fitch, MD, FACP, FOMA According to the World Health Organization, obesity is a global health
epidemic, which has nearly tripled in prevalence since 1975.
Worldwide in 2016, 13% of adults 18 years and older had obesity (body
mass index $ 30 kg/m2) and 39% were overweight (body mass index
25.0 to 29.9 kg/m2). In the United States, approximately 35% of adults
have obesity and 31% are overweight. Obesity increases stress
throughout the musculoskeletal system and carries a higher risk for
the development of osteoarthritis and various other musculoskeletal
conditions. When patients with obesity undergo orthopaedic
procedures, weight loss is a critical aspect to appropriate preoperative
counseling and treatment. Weight loss can improve obesity-related
comorbidities such as metabolic syndrome, diabetes, cardiovascular
disease, and obstructive sleep apnea, which in turn may reduce
complications, minimize long-term joint stress, and improve
outcomes among patients undergoing orthopaedic procedures. The
effects of obesity on patients undergoing total joint arthroplasty has
been previously described, with reported associations of increased
risk of infection, revision, blood loss, venous thromboembolism, and
overall costs. The purpose of this article was to provide orthopaedic
From the Peachtree Orthopedics, Atlanta, GA
(Carreira), Orthopaedic Surgery Resident,
surgeons with strategies for obesity treatment.
Department of Orthopaedic Surgery, WellStar
Atlanta Medical Center, Atlanta, GA (J.W.

A
Robison), Regional Dietitian, Ethica Health and ccording to the World Health Organization, obesity is a global health
Retirement Communities, Gray, GA (S. Robison),
epidemic, which has nearly tripled in prevalence since 1975. World-
and Massachusetts Hospital Weight Center,
Division of Endocrinology, Faculty Harvard wide in 2016, 13% of adults 18 years and older had obesity (body
Medical School, Boston, MA (Fitch). mass index [BMI] $ 30 kg/m2) and 39% were overweight (BMI 25.0 to
Robison: Support for attending meetings and/or 29.9 kg/m2). In the United States, approximately 35% of adults have obesity
travel: Johnson and Johnson (Depuy); Fitch:
Participation on a Data Safety Monitoring Board and 31% are overweight.1 BMI is a person’s weight in kilograms (or pounds)
or Advisory Board for the following entities: Jenny divided by the square of height in meters (or feet). Obesity increases stress
Craig, Novo Nordisk, Gelesis, MsMedicine,
Found Leadership or fiduciary role in other board,
throughout the musculoskeletal system and carries a higher risk for the
society, committee or advocacy group, paid or development of osteoarthritis and various other musculoskeletal conditions.
unpaid: President Elect Obesity Medical
Sarcopenic obesity is associated with an increased risk of all-cause mortality,
Association, Ex-Officio member BOT Obesity
Action Coalition. new-onset depression, gastric cancer, insulin resistance, vitamin D deficiency,
J Am Acad Orthop Surg 2022;30:e1563-e1570 and inflammation.2 Treatment of sarcopenic obesity includes strength
DOI: 10.5435/JAAOS-D-21-01083 training exercise programs. When patients with obesity undergo orthopaedic
Copyright 2022 by the American Academy of
procedures, weight loss is a critical aspect to appropriate preoperative
Orthopaedic Surgeons. counseling and treatment. Weight loss can improve obesity-related

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Obesity Treatment

comorbidities such as metabolic syndrome, diabetes, spinach, and squash. One-fourth of the plate should
cardiovascular disease, and obstructive sleep apnea, contain whole grains such as brown rice, wild rice, qui-
which in turn may reduce complications, minimize long- noa, and oats. The remaining fourth should include lean
term joint stress, and improve outcomes among patients proteins such as fish and poultry while limiting intake of
undergoing orthopaedic procedures.3 The effects of red meats high in saturated fat. Healthy oils such as
obesity on patients undergoing total joint arthroplasty avocado oil and olive oil may be used in moderation.
has been previously described, with reported associa- Sugar-sweetened beverages should be avoided.
tions of increased risk of infection, revision, blood loss, Nutritional quality in the setting of weight loss may be
venous thromboembolism, and overall costs.2 When beneficial to orthopaedic surgery for appropriate pro-
initiating care for patients with obesity, surgeons should tein and other macronutrient intake. Previous studies
involve primary care practitioners and refer patients to have shown albumin ,3.5 g/dL, total lymphocyte
registered dietitians and other weight loss specialists in count ,1,500 cells/mm3, and/or transferrin level
an attempt to optimize BMI before scheduling surgery. ,200 mg/dL to be serum markers of malnutrition and
The purpose of this article was to provide orthopaedic risk factors of wound complications, including surgical
surgeons with strategies for obesity treatment. The fol- site infections.5-7 Nutritional quality is an especially
lowing sections will highlight nutritional quality, caloric important consideration in patients who are restricting
reduction, exercise, bariatric surgery, pharmacotherapy, calories to optimize weight reduction before surgery to
lifestyle, genetics, weight gain prevention, postoperative ensure their macronutrient needs are being met. Despite
weight management, endocrine, and orthopaedic out- this link between malnutrition and morbidity after
comes as they relate to weight reduction and obesity orthopaedic surgery, to the best of our knowledge, there
treatment. Where indicated, we have provided take has not been a study to clearly demonstrate that
away points and action items that will allow ortho- nutritional quality leads to improved outcomes in
paedic surgeons to more easily implement these findings orthopaedic surgery specifically.
into their practice. In addition, we have created a patient
handout that summarizes these points, which is included Take Away
in the Supplementary Data File, http://links.lww.com/ Weight loss is promoted through diets rich in vegetables,
JAAOS/A844. fruits, lean proteins, and whole grains. When
visualizing a plate, half of the plate should be composed
of nonstarchy vegetables. The remainder of the plate
should be split equally to contain a lean protein source
Nutritional Quality and a whole grain food item.
Although the concept that calories consumed must be
lower than calories expended to achieve weight loss is Action Items
accurate, not all calories are equal in nutritional quality. Copies of the Healthy Eating Plate should be available to
A study that included over 120,000 participants and provide patients a tangible visual to follow. The handout
spanned over 20 years found weight gain to be associated included in the Supplementary Data File, http://links.
with increased consumption of lower quality foods such lww.com/JAAOS/A844, includes a copy with a QR code
as potato chips, potatoes, sugar-sweetened beverages, link.
unprocessed red meats, and processed red meats. Con-
trarily, weight loss occurred with increased consumption
of high-quality foods such as vegetables, whole grains, Caloric Reduction
fruits, nuts, and yogurt.4 Hall et al in 2019 showed that Caloric restriction is defined as the reduction of daily
ultra-processed diets cause excess calorie intake and calorie intake below what is typical for an individual. A
weight gain in a pivotal inpatient randomized controlled well-balanced, calorie-restricted diet is the most com-
trial of ad libitum food intake. monly prescribed method for weight loss. Daily calories
The Harvard Schools of Public Health and Medicine are decreased to allow for fat stores to be used to meet
developed the Healthy Eating Plate to provide the daily energy requirements. A calorie reduction of 500 to
healthiest choices in various food groups. Half of a meal 1,000 kcal from one’s typical daily consumption should
should be composed of nonstarchy vegetables and fruits. be adequate to meet this goal. In most cases, this equates
Examples of nonstarchy vegetables include asparagus, to an allowance of 1,200 to 1800 kcal daily. The general
broccoli, Brussels sprouts, cabbage, cucumbers, peppers, guideline for caloric restriction is to obtain 50% to 55%

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 Dominic Carreira, MD, et al

Review Article
of total kcals from carbohydrates, 15% to 25% of total programs, such as aquatic jogging or water aerobics,
kcals from protein, and no more than 30% of total kcals offer a low-impact alternative that patients with joint
from fat. However, calorie-restricted diets should be pain or reduced mobility may find more feasible than
individualized, and vitamin and mineral supplements walking or jogging on land. Aquatic jogging programs
are typically recommended with caloric restrictions of can reduce body fat mass and waist circumference.
1,200 kcal per day for women or 1800 kcal per day for Aerobic exercises in water is equivalent to aerobic ex-
men.8 Consulting with a registered dietitian in the ercises on land regarding body composition assuming
presence of other disease states may be warranted. that similar duration, intensity, and frequency are used.11
A web-based search of “aquatic physical therapy near
Take Away me” will typically result in a list of providers in the area.
A well-balanced, calorie-restricted diet is the most com- Patients should be educated that exercise programs that
monly prescribed method for weight loss. A calorie include aerobic activity, regardless of the specific type, will
reduction of 500 to 1,000 kcals from one’s typical daily likely improve the chances of long-term weight mainte-
consumption should be adequate for fat stores to be nance. However, although exercise has many positive
used in meeting daily energy requirements. This typi- benefits, the extent of its contribution to weight loss is much
cally equates to a total daily calorie allowance of 1,200 less than that of nutritional interventions, with a more
to 1800 kcals. important role of weight maintenance. The exercise should
be realistically done at least four or five days weekly; con-
Action Items sistency is crucial for achieving and maintaining weight loss
A referral list of local dietitians or nutritionists should be goals. Most individuals may be able to achieve weight
provided to patients with complex medical comorbidities reduction with as little as 30 minutes of walking a day when
or to those who are interested in best strategizing their combined with changes in dietary intake.10
dietary changes and weight loss goals. There are a num- The benefits of exercise go beyond weight reduction.
ber of smartphone applications that can be used to assist Although there is no literature to the best of our knowledge
with tracking macronutrients and total caloric intake; that directly demonstrates the benefit of exercise as a
these are provided in the handout in the Supplementary means for weight loss on outcomes after orthopaedic
Data File, http://links.lww.com/JAAOS/A844. procedures specifically, exercise remains an important
adjunct to dietary changes in weight reduction and weight
maintenance strategies for many patients because exer-
Exercise cising has positive metabolic effects that extend beyond
Many patients understand the role of regular exercise for weight loss alone. For example, many patients with obesity
their overall health, and physical activity may play an have comorbidities including type 2 diabetes mellitus
important role in a weight reduction program. Patients because those with BMI .35 kg/m2 are 20 times more
seeking to begin an exercise program may feel over- likely to develop diabetes than those with a BMI between
whelmed by the many options that exist to exercise (gym 18.5 and 24.9 kg/m2.12 In patients with obesity and type 2
memberships or popular group fitness classes such as diabetes, both aerobic exercise and resistance training
Orangetheory, CrossFit, or Pure Barre). A randomized programs can improve insulin sensitivity and reduce
trial that compared the effects of aerobic exercise with HbA1c.13,14 Additional studies have demonstrated a dose-
resistance training on total body mass and fat mass in response relationship between exercise and reduction of
overweight individuals or individuals with obesity found central obesity, which is related to metabolic comorbidities
that those individuals who engaged in aerobic exercise often encountered in patients with obesity (ie, cardiovas-
reduced total body and fat mass more than those who cular disease, diabetes, hypertension).10 One might infer
participated in resistance training alone while those who that a link exists between these metabolic improvements
participated in resistance training increased lean body and outcomes after orthopaedic procedures. Additional
mass more than those who engaged in aerobic training study is needed to compare the various means of weight
alone.9 The STRRIDE study demonstrated that an loss (ie, dietary changes, exercise) in the setting of out-
increased amount and intensity of aerobic exercises comes after orthopaedic procedures. Possibly, not all ve-
correlated with the prevention or reduction of visceral hicles to weight loss are equivalent means to the same end.
and subcutaneous abdominal fat.10 Other studies also In summary, patients should pick an activity that they
have supported the dose-response relation between aer- find tolerable and can complete consistently; for some that
obic exercises and visceral fat reduction. Aquatic exercise may be as simple as walking 30 minutes 5 days per week.

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Obesity Treatment

Table 1. Buchwald et al. (2004) demonstrated most agement of musculoskeletal conditions because there is an
bariatric surgery patients experienced improvement of association between gastric bypass surgery and marginal
their related comorbidities ulcerations. However, with gastric sleeve surgery, there are
no apparent NSAID-related complications.19
Resolved or
Condition Improved Resolved
Bariatric surgery is one way to achieve weight loss in
patients with morbid obesity who have failed conservative
Hypertension 81.8% 65.6%
measures. Patients with obesity have been referred for
Obstructive 80.6% 87.9% bariatric surgery to meet preoperative BMI parameters (ie,
sleep apnea
BMI , 40 mg/kg2 before TKA) in hopes of reducing the
Diabetes mellitus 85.4% 76.8% perioperative risks associated with obesity. However,
conflicting evidence exists surrounding preoperative
bariatric surgery for weight reduction and postoperative
Take Away complications in orthopaedic surgery. A recent retro-
Consistent exercise is a beneficial addition to a restricted
spective cohort demonstrated that those patients who had
calorie diet for weight loss and overall health. Aquatic
undergone bariatric surgery before total knee arthro-
exercise programs, aerobics, and resistance training are
plasty were at increased risk of mortality, pneumonia,
all beneficial.
and implant failure.20 In this particular report, the au-
thors demonstrated that specific complications were more
often associated with specific types of bariatric surgery.
Bariatric Surgery Another report demonstrated that those who underwent
Bariatric surgery is a viable option for patients with obesity bariatric surgery before lower extremity total joint ar-
who qualify because of the severity of their disease. Ac- throplasty had shorter surgical time and length of stay,
cording to the American Society for Metabolic and Bari- but did not reduce long-term risks of dislocation, peri-
atric Surgery, approximately 256,000 bariatric surgery prosthetic infection, periprosthetic fracture, or revision.21
procedures were conducted in the United States in 2019, Another report comparing patients with obesity who
which is an increase from 158,000 in 2011. Bariatric received bariatric surgery before total joint arthroplasty
surgery has been the most effective and long-lasting of the hip or knee demonstrated a reduced comorbidity
treatment modality for patients with Class 3 obesity burden and reduced complication rate, although this did
(body mass index $ 40 kg/m2). Patients typically expe- not lead to a reduction in revision rates.22 Other meta-
rience most of their weight loss within one to two years analyses report that bariatric surgery before hip or knee
after their bariatric surgery, with maintenance of weight arthroplasty does not markedly reduce perioperative
loss leading to improvements in conditions related to complications or improve clinical outcomes.23 Future
obesity, including but not limited to type 2 diabetes, work is needed to further examine the effects of bariatric
hypertension, heart disease, and sleep apnea.15 A 2004 surgery on outcomes of orthopaedic procedures.
meta-analysis including 136 primary studies and 22,094
patients found that most bariatric surgery patients Take Away
experienced improvement, if not complete resolution, of Bariatric surgery is a safe and effective method for weight
their related comorbidities, as given in Table 1.16 loss in patients with obesity who qualify because of their
In addition, patients can be counseled on the risk disease severity.
reduction of certain neoplasms that follow bariatric
surgery in some populations. Studies suggest that bari- Action Items
atric surgery improves cancer outcomes in some patients Patients whose BMI is $ 40 kg/m2 who have failed to
with obesity, with lower incidences of breast and colo- lose weight with diet and exercise should be counseled
rectal cancers in the bariatric surgery cohort.17 on the potential benefits of pursuing bariatric surgery.
Potential candidates should be advised of the safety Referral to bariatric surgery is recommended.
profile for bariatric surgeries, with 30-day mortality rates of
those undergoing laparoscopic Roux-en-Y gastric bypass or
laparoscopic adjustable gastric banding at 0.3%, with 4.3%
of patients experiencing at least one major adverse out- Pharmacotherapy
come.18 The inability to use NSAIDs after some bariatric Multiple pharmacotherapeutic options exist for patients
surgical procedures is a long-term limitation in the man- desiring weight reduction. Body weight regulation is a

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 Dominic Carreira, MD, et al

Review Article
complex, multifaceted balance of factors including energy has recently approved semaglutide as an antiobesity
intake, energy expenditure, genetics, environment, and drug in adults when used in combination with lifestyle
culture. Pharmacotherapeutics typically aim to alter one of changes. Patients should be counseled to consult with
three mechanisms of weight regulation: energy intake, their primary care physician to determine what med-
nutrient handling, and energy expenditure. Antiobesity ication profile best suits their needs.
medications have been recommended for patients with Take away: Although pharmacotherapeutics have
BMI $ 30 kg/m2 or those with BMI $ 27 kg/m2 with historically had questionable efficacy and tolerance
concomitant obesity-related risk factors or comorbidities, profiles, recent studies are promising. Patients should be
such as type 2 diabetes mellitus, hypertension, hyper- referred to their primary care physician or an obesity
lipidemia, coronary heart disease, and sleep apnea.24 medicine specialist for recommendations.
Historically, antiobesity medications have had a ques- Action items: Patients should be informed that despite
tionable past track record, with multiple drugs being pulled questionable track records of older weight loss medi-
from the market by the US Food and Drug Administration cations, newer medications are now available that have
in the 1990s because of cardiovascular toxicities. One of the proven to be effective adjuncts to weight loss. They
more infamous medications that were ultimately removed should inquire about these medications at their visit with
from the market was ephedra (ma-huang). In addition, the their primary care provider or endocrinologist.
efficacy of many of the available medications has been
questioned. A 2005 meta-analysis examining the phar-
macologic treatment of obesity demonstrated that the
amount of extra weight loss associated with the medi- Lifestyle
cations under review was modest, with an average loss Long-term lifestyle changes are often needed to initiate
of ,5 kg at 1 year.25 and maintain weight loss for many patients; however,
Weight reduction as small as 5% of body weight can initiating long-term changes to activity and eating
markedly influence obesity-related risk factors such as type behavior can be quite difficult. Regarding weight loss
2 diabetes, hypertension, and others. Combination therapy monitoring, studies have shown that daily self-weighing
with phentermine and topiramate is the most commonly improves weight loss and adoption of weight control
prescribed antiobesity medication (brand name Qsymia©). behaviors, with higher frequency associated with greater
This combination therapy demonstrated that 67% were weight loss.29
able to lose 5% of their weight versus 17% in the placebo Comprehensive lifestyle modification programs
group and 47% of patients were able to lose 10% of their in groups have been effective at achieving and main-
weight versus 7% in the placebo group.26 Other common taining weight loss. These group therapies typically
appetite suppressant medications (anoretic agents) include involve weekly meetings for the first 6 months, followed
phentermine, diethylpropion, and topiramate. One of the by meetings every two weeks for the second 6 months,
most studied absorption-altering drugs is orlistat, which with registered dietitians, psychologists, exercise spe-
promotes weight loss by inhibiting lipase to prevent fat cialists, and other health professionals. Group sessions
absorption.27 can be more effective and less expensive than individual
More recent studies show increasing promise for sessions. These sessions are designed to give participants
more successful obesity treatment. The STEP 1 trial in the motivation to maintain weight control behaviors,
NEJM demonstrated that overweight patients or pa- such as consistent exercise, caloric reduction with peri-
tients with obesity who were treated with weekly sub- odic food intake recording, and weight loss monitoring.
cutaneous semaglutide injections combined with These behaviors mirror those practiced by participants in
lifestyle modifications lost markedly more weight than the National Weight Control Registry.30 With advances
those treated with placebo and lifestyle changes in technology, patients may stay connected with their
alone—with mild-to-moderate adverse effects that peers through applications on their smartphones and
were transient.28 In this pivotal study, participants tablets that are designed to promote social interaction
who received semaglutide experienced a mean change and accountability.
in body weight of 214.9% compared with 22.4% in
the control group. In addition, these patients had Take Away
greater improvements in cardiometabolic risk factors Lifestyle modifications along with community support
and patient-reported physical functioning from base- are effective, especially when elements of inspiration and
line than those who received the placebo.28 The FDA accountability are incorporated.

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Obesity Treatment

about others’ success stories and join if interested. The

Genetics link to the website is attached with the handout in the
The development of obesity also has a genetic component. Supplementary Data File, http://links.lww.com/JAAOS/
An international study of 53 pairs of monozygotic twins A844.
demonstrated that 50 to 70% variance in the body mass
index is attributable to genetic differences.31 Although rare
monogenic forms of obesity exist, most often obesity re- Postoperative Weight Management
sults from a polygenic component combined with envi-
Although many patients may hope to lose weight after
ronmental factors.32 A recent genome-wide association
improving their mobility postoperatively, several studies
study (GWAS) of approximately 700,000 individuals of
have demonstrated this weight loss not to occur. There have
European ancestry revealed 941 single nucleotide poly-
been several studies examining patient factors on postop-
morphisms (SNPs) associated with body mass index.
erative weight change.33,34 Ast et al33 reported in their
Multiple studies have linked the FTO gene as a main
review of 3,893 total hip arthroplasties and 3,036 total
contributor to obesity in the European population.32
knee arthroplasties that most patients maintained their
Although consistency and adherence to lifestyle
body mass index after their surgeries. In their review,
modification is a major determinant of successful weight
female sex, greater BMI, and total knee arthroplasty were
loss, there is some variability between individuals in
significant predictors of weight loss postoperatively
weight loss response, with genetics serving as a factor.
(P , 0.05). In addition, a higher preoperative functional
level was significantly associated with a lower likelihood of
Weight Gain Prevention
weight gain at two-year follow-up (P , 0.05).34 These
Unfortunately, it is common for individuals who have
findings are consistent with other studies of joint arthro-
successfully met their weight loss goals to regain the lost
plasty surgery, with lower preoperative BMI and young
weight. Caloric requirements for weight maintenance
age being associated with weight gain postoperatively.34 In
after weight reduction are approximately 25% lower than
addition, it has been reported that female patients are more
the original weight. The National Weight Control Regis-
likely to lose weight postoperatively. Most patients with
try (NWCR) was developed to determine key factors in
obesity do not lose weight after hip or knee arthroplasty,
successful long-term weight loss. The NWCR currently
which reinforces the need for preoperative counseling and
tracks over 10,000 individuals who have lost notable
weight reduction strategic planning.
weight over the long term. In general, the NWCR partic-
Action items: Based on total hip and knee arthroplasty
ipants have reported eating breakfast every day, assessing
outcomes related to weight loss, patients should be edu-
weight at least once per week, watching less than 10 hours
cated that although it is possible to lose weight after
of television per week, and exercising an average of 1 hour
surgery, studies have shown that many patients do not
per day. The chances of long-term success in weight
lose weight afterward. This information may help pa-
maintenance increase after individuals have been able to
tients develop appropriate expectations and strategies for
maintain weight loss for 2 to 5 years.30 The addition of
weight loss before and after surgery.
pharmacotherapy to lifestyle changes increases successful
weight maintenance when the pharmacotherapy is con-
tinued. Like any chronic disease with multiple causes,
long-term treatment with medication often is warranted. Endocrine
A number of endocrine abnormalities exist that are
Take Away associated with obesity. Type 2 diabetes, thyroid disease,
The following habits have helped promote weight polycystic ovarian disease (PCOS), fatty liver disease,
maintenance: eating breakfast daily, weighing in at and hypogonadism in men (low testosterone) are all
least weekly, watching television less than 10 hours associated with obesity. In patients with obesity and
per week, and exercising an average of 1 hour daily. type 2 diabetes, providers may consider limiting weight-
Addition of pharmacotherapy to lifestyle behaviors im- promoting medications such as insulin and sulfonylureas
proves weight maintenance. and replacing them with weight loss–promoting medi-
cations such as GLP-1, SGLT-2, and metformin.35 Patients
Action Items with obesity should be screened for thyroid abnormalities
Patients should be provided information on the National so that deficiency can be replaced to normal levels.
Weight Control Registry program so that they can read Although thyroid hormone replacement has not shown any

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 Dominic Carreira, MD, et al

Review Article
consistent weight loss benefit, it is reasonable that hormone and individuals with obesity have similar clinical out-
replacement therapies may enhance patients’ energy and comes after total hip and knee arthroplasty.40
mood. Patients with improved energy and mood may be The effect of obesity on outcomes in patients undergo-
more likely to adhere to lifestyle changes, resulting in ing orthopaedic procedures has been well described.
weight loss over time. PCOS is diagnosed clinically, and However, there is no evidence to support an optimal pre-
treating PCOS does not typically result in weight loss.36 operative duration for nonsurgical weight reduction
Although these obesity-associated endocrine abnormalities strategies before orthopaedic surgery. In addition, there is
may warrant personalized treatment modalities from limited literature supporting a minimum amount of clini-
endocrine specialists, none of the specialized treatments cally meaningful weight reduction to optimize outcomes
have been proven to be superior to treating the obesity after orthopaedic procedures. A retrospective review
through medication, surgery, diet, and lifestyle changes. demonstrated that patients with BMI . 40 kg/m2 who
Patients should be referred to their primary care physicians lost $ 20 pounds before TKA were associated with
or endocrine specialists for optimized, specialized treatment shorter length of stay and fewer discharges to a facility,
modalities geared toward their specific condition; however, but not in those who lost five or 10 pounds.41 However,
fundamentally, their obesity must be addressed first and the literature remains somewhat ambiguous regarding
foremost. preoperative weight reduction on postoperative outcomes
after orthopaedic procedures. Literature exists demon-
Take Away strating an “obesity paradox” in joint arthroplasty,
While endocrinopathies should be noted and optimized, whereby patients with obesity have lower mortality
treatment remains best directed toward obesity itself. and/or complications after these procedures.42,43 There
are also reports supporting the notion that notable pre-
operative weight reduction can result in postoperative
rebound weight gain and inferior outcomes after ortho-
Orthopaedic Outcomes paedic procedures.44,45 Additional research in this area is
Obesity is associated with several medical comorbidities, needed to help direct patients establish realistic goals.
including diabetes, pulmonary disease, cardiovascular dis-
ease, and obstructive sleep apnea. These comorbidities place Conclusion
patients with obesity at an increased risk of perioperative
Obesity is a complex, multifaceted disease with high
complications, including venous thromboembolism, pul-
prevalence. This review should not be considered
monary embolism, and surgical site infection.2 Biome-
exhaustive but rather is intended to provide busy ortho-
chanical analysis work has shown that obesity can result in
paedic surgeons with an updated review of the current
higher THA dislocation rates.37 Uncontrolled diabetes has
best literature on how to best help treat their population
been shown to increase risk of surgical site infection. In a
of patients who are overweight or have obesity.
retrospective review of 6,108 patients who underwent
primary hip or knee arthroplasty and those with BMI . 50
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Obesity Treatment

8. Krause MV, Mahan LK, Escott-Stump S, Raymond JL: Krause’s food & 27. Sjöström L, Rissanen A, Andersen T: Randomised placebo-controlled trial
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