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The Effect of Bariatric Surgery Prior to Lower-Extremity Total Joint Arthroplasty: A Systematic Review.

ABSTRACT: Background:Obesity is an independent risk factor for osteoarthritis and has been associated with increased rate of complications following lower-extremity total joint arthroplasty (TJA). Bariatric surgery (BS) is a surgical option for weight loss and for reducing obesity-related comorbidities in morbidly obese patients. Purpose/Questions:The goal of this systematic review was to answer the following questions: (1) Does BS prior to TJA correlate with lower post-operative complication rates in morbidly obese patients undergoing TJA? (2) Does BS have an impact on revision rates following TJA? Methods:Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist, a systematic review of medical databases (PubMed/ MEDLINE, Cochrane Library, Web of Science, and Clinicaltrials.gov) was undertaken for articles published in English from January 1990 to September 2018. Inclusion criteria were studies that included at least ten patients who underwent BS prior to TJA, collected data on complications or other outcomes, and followed patients for at least 90 days after TJA. A descriptive and critical analysis of the results was performed. Results:From 799 studies, 13 met inclusion criteria. A total of 11,770 patients who had undergone bariatric surgery prior to TJA were analyzed. The quality of the evidence ranged between moderate and high. There was no consensus on the effect of previous BS on early- to short-term outcomes reported after TJA. Conclusion:The literature remains conflicted on the impact of BS prior to TJA on early, short-term, and long-term complications after TJA. Additional well-matched, observational studies may further our understanding of the impact of BS prior to TJA on outcomes. In particular the effect of various types of BS prior to TJA on outcomes has yet to be elucidated. Ideally, prospective studies with higher level of evidence will be more definitive on the effects of BS prior to TJA.Prospero Registration Number: CRD42016043025.

SUBMITTER: Gu A

PROVIDER: S-EPMC6609675 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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The Effect of Bariatric Surgery Prior to Lower-Extremity Total Joint Arthroplasty: A Systematic Review.

Gu Alex A Cohen Jordan S JS Malahias Michael-Alexander MA Lee Danny D Sculco Peter K PK McLawhorn Alexander S AS

HSS journal : the musculoskeletal journal of Hospital for Special Surgery 20190409 2

<h4>Background</h4>Obesity is an independent risk factor for osteoarthritis and has been associated with increased rate of complications following lower-extremity total joint arthroplasty (TJA). Bariatric surgery (BS) is a surgical option for weight loss and for reducing obesity-related comorbidities in morbidly obese patients.<h4>Purpose/questions</h4>The goal of this systematic review was to answer the following questions: (1) Does BS prior to TJA correlate with lower post-operative complicati ...[more]

PMID: 31327952

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Project description:ImportancePeople with severe obesity who undergo a total knee arthroplasty (TKA) for osteoarthritis (OA) are at higher risk of short-term and long-term complications compared with people with reference (<30) body mass index (BMI; weight in kilograms divided by height in meters squared). It is not known whether weight loss before TKA modifies this risk.ObjectiveTo determine whether outcomes are improved by undergoing bariatric surgery before TKA in people with BMI greater than or equal to 35 and end-stage OA.Design, setting, and participantsThis parallel-group, assessor-blinded, randomized clinical trial was conducted between May 2012 and June 2020 with a minimum follow-up of 12 months after TKA. TKA was performed at a tertiary referral university-affiliated public hospital, and bariatric surgery was performed at a private hospital facility and a university-affiliated private practice. Data analysis was performed from February to July 2021.InterventionsBariatric surgery compared with usual weight management advice (treatment as usual [TAU]) in people scheduled for TKA.Main outcomes and measuresThe primary outcome was complications of TKA measured by a composite of death from any cause, perioperative or postoperative complications resulting in a discharge delay, unplanned procedure, or readmission for at least 12 months after TKA. Secondary outcomes included hospital bed day utilization, anthropomorphic measures, and patient-reported outcomes.ResultsEighty-two patients waiting for TKA were randomized to undergo bariatric surgery (41 patients) or TAU (41 patients). Of the 82 participants, 66 (80.5%) were women, the mean (SD) age was 57.8 (4.9) years, and the mean (SD) BMI was 43.8 (5.5). Thirty-nine participants (95.1%) in the intervention group underwent laparoscopic adjustable gastric banding, and 29 (70.7%) subsequently underwent TKA. Thirty-nine patients (95.1%) in the TAU group underwent TKA. Six patients (14.6%) in the intervention group incurred the primary outcome (median follow-up, 24 months), compared with 15 (36.6%) in the TAU group (median follow-up, 27 months) (difference, 22.0%; 95% CI, 3.7% to 40.3%; P = .02). The between-group difference in BMI at 12 months was -6.32 (95% CI, -7.90 to -4.50; P < .001) in favor of the intervention group. TKA was declined by 12 participants (29.3%) in the intervention group because of symptom improvement, whereas 2 participants (4.9%) in the TAU group declined TKA (difference, 24.4%; 95% CI, 9.0% to 39.8%; P = .003).Conclusions and relevanceWeight loss following bariatric surgery reduced the risk of complications of TKA in people with BMI greater than or equal to 35. Significantly fewer participants required TKA following weight loss, contributing to this finding.Trial registrationAustralian New Zealand Clinical Trials Registry Number: ACTRN12611001178932.

Project description:BackgroundPrior studies have suggested that preoperative dehydration increases odds of perioperative complications in several areas of orthopedic surgery. This study aimed to evaluate whether preoperative hydration status is associated with the incidence of short-term complications after primary total joint arthroplasty.MethodsThe 2012-2019 National Surgical Quality Improvement Program (NSQIP) database was used to explore the relationship between preoperative dehydration (ratio of preoperative BUN divided by preoperative Creatinine (BUN/Creatinine) > 20) and perioperative outcomes of total hip (THA) and total knee arthroplasty (TKA) patients. Univariate comparisons and multivariate regression analyses were conducted to identify specific complications that occurred more often in patients with preoperative dehydration.ResultsOf 188,629 THA and 332,485 TKA patients, 46.3 and 47.0% had preoperative dehydration, respectively. After controlling for demographics and comorbidities, dehydrated THA patients were no more likely to experience a complication compared to their non-dehydrated counterparts (relative risk [RR] = 0.97, 99.7% Confidence Interval [CI]: 0.92-1.03, P = 0.138) nor increased risk of blood transfusion (RR = 1.02, CI = 0.96-1.08, P = 0.408). Similar to THA patients, dehydrated TKA patients were not more likely to have a complication after surgery (RR = 0.97, CI = 0.92-1.03, P = 0.138) and were at no greater risk of transfusion (RR = 1.02, CI = 0.96-1.07, P = 0.408). A sub-analysis covering only patients with BUN and Cr values determined within 24 h after surgery was performed and similarly found no significant increase in perioperative complications or transfusion.ConclusionOverall, preoperative dehydration in patients undergoing THA/TKA did not appear to increase risk of transfusion or other perioperative complications. Further research is needed to characterize the role of hydration prior to elective total joint arthroplasty.

Project description:Objective: The current review was designed to assess the impact of prior intra-articular injections on the risk of prosthetic joint infection (PJI) in patients undergoing total joint arthroplasty (TJA) with a focus on the timing of injection before surgery. Methods: The databases of PubMed, Embase and Google Scholar were searched up to 15th June 2021. All studies comparing the incidence of PJI with and without prior intra-articular injections were included. Risk ratios (RR) with 95% confidence intervals were calculated for PJI. Results: Nineteen studies were included. Both corticosteroids and hyaluronic acid injections were used before TJA in the included studies. Overall, comparing 127,163 patients with prior intra-articular injections and 394,104 patients without any injections, we noted a statistically significant increased risk of PJI in the injection group (RR 1.24 95% CI: 1.11, 1.38 I2 = 48% p = 0.002). On subgroup analysis, there was a statistically significant increased risk of PJI in the injection group in studies where intra-articular injections were administered <12 months before surgery (RR 1.18 95% CI: 1.10, 1.27 I2 = 7% p < 0.00001). Furthermore, on meta-analysis, we noted non-significant but increased risk of PJI when injections were administered 1 month (RR 1.47 95% CI: 0.88, 2.46 I2 = 77% p = 0.14), 0-3 months (RR 1.22 95% CI: 0.96, 1.56 I2 = 84% p = 0.11), and 3-6 months (RR 1.16 95% CI: 0.99, 1.35 I2 = 49% p = 0.06) before surgery. Conclusion: Our results indicate that patients with prior intra-articular injections have a small but statistically significant increased risk of PJI after TJA. Considering that PJI is a catastrophic complication with huge financial burden, morbidity and mortality; the clinical significance of this small risk cannot be dismissed. The question of the timing of injections and the risk of PJI still remains and can have a significant impact on the decision making. Systematic Review Registration: PROSPERO: CRD42021258297.

Project description:BackgroundNo validated pre-operative cardiac risk stratification tool exists that is specific for total hip and total knee arthroplasty (THA and TKA, respectively). To reduce the risk of post-operative cardiac complication, surgeons need clear guidance on which patients are likely to benefit from pre-operative cardiac optimisation. This is particularly important for asymptomatic patients, where the need is harder to determine.MethodsPrimary THA and TKA performed between January 1, 2010, and December 31, 2017, were identified from a single orthopaedic practice. Over 25 risk factors were evaluated as predictors for patients requiring additional cardiac investigation beyond an ECG and echocardiogram, and for cardiac abnormality detected upon additional investigation. A multivariate logistic regression was conducted using significant predictor variables identified from inferential statistics. A series of predictive scores were constructed and weighted to identify the influence of each variable on the ability to predict the detection of cardiac abnormality pre-operatively.ResultsThree hundred seventy-four patients were eligible for inclusion. Increasing age (p < 0.001), history of cerebrovascular accident (p = 0.018), family history of cardiovascular disease (FHx of CVD) (p < 0.001) and decreased ejection fraction (EF) (p < 0.001) were significant predictors of additional cardiac investigation being required. Increasing age (p = 0.003), male gender (p = 0.042), FHx of CVD (p = 0.001) and a reduced EF (p < 0.001) were significantly predictive for the detection of cardiac abnormality upon additional cardiac investigation.ConclusionsIncreasing age, male gender, FHx of CVD and decreased ejection fraction are important risk factors to consider for pre-operative cardiac optimisation in THA and TKA patients. These findings can be applied towards future predictive models, to determine which asymptomatic patients are likely to benefit from pre-operative cardiac referral.

Project description:BackgroundUtilization of arthroplasty is increasing, but there are little data exploring the causes of this increase. The objective of this study was to examine the relationship between new programs for arthroplasty of the lower extremity joints and the utilization of arthroplasty.MethodsWe identified twenty-four markets (hospital referral regions) that experienced the entry of new physician-owned specialty hospitals, using 1991 to 2005 Medicare data. We matched each market with a new specialty hospital to two different control markets (one market with a new arthroplasty program in a general hospital and one market without a new arthroplasty program), using a propensity score that accounted for market supply and demand for orthopaedic surgery and the regulatory environment. We compared the utilization of arthroplasty of the lower extremity joints (total hip arthroplasty and total knee arthroplasty) in each group of markets over a five-year window, extending from two years before to three years after the entry of new orthopaedic surgery programs.ResultsThe twenty-four markets with new specialty orthopaedic hospitals had higher utilization of arthroplasty at baseline (10.9 arthroplasties per 1000 Medicare beneficiaries per year) and follow-up (12.7 per 1000 beneficiaries) compared with the twenty-four markets with new arthroplasty programs in general hospitals (9.7 and 11.4, respectively) and the twenty-four markets with no new programs (9.9 and 11.3), although the differences were not significant (p > 0.05). Growth in the utilization of arthroplasty was similar in markets with new specialty hospitals before (an increase of 0.63 procedure per 1000 beneficiaries per year) and after the entry of new specialty hospitals (an increase of 0.39) compared with markets with new surgery programs in general hospitals (an increase of 0.24 before and 0.43 after) and markets with no new programs (an increase of 0.38 before and 0.33 after the entry of new specialty hospitals) (p > 0.05 for all comparisons).ConclusionsThe utilization of arthroplasty is increasing at similar rates in markets with and without new arthroplasty programs.

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The Effect of Bariatric Surgery Prior to Lower-Extremity Total Joint Arthroplasty: A Systematic Review.

Publications

The Effect of Bariatric Surgery Prior to Lower-Extremity Total Joint Arthroplasty: A Systematic Review.

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