Lose Weight And Knee Surgery
In a new study, U of A researchers found no evidence that losing weight before undergoing knee surgery is beneficial for patients with osteoarthritis. The research suggests BMI may not be a good indicator of how patients will fare after surgery. (Photo: Obesity Canada, CC BY-NC-ND 2.0)
Researchers in the Faculty of Rehabilitation Medicine found that weight loss before surgery may not be beneficial for people with advanced knee osteoarthritis.
Medical practitioners have long advised patients to lose weight before knee surgery. Patients living with obesity, defined by a body mass index (BMI) of 30 or higher, are especially warned of surgical complications, risk of infection and poor outcomes due to their high BMI.
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“While there’s evidence that a higher BMI equals a potentially higher surgical risk, that doesn’t mean that if a patient reduces their BMI, even a point or two, that it would be good for them, ” said lead author Kristine Godziuk, a post-doctoral fellow in the Department of Occupational Therapy.
The research team reviewed clinical practice guidelines and other clinically influential literature from the past 10 years for evidence that weight loss is helpful for patients. “We didn’t find any, ” said Godziuk.
Osteoarthritis affects more than 300 million people worldwide, with the knee being the most common joint affected. Factors like aging and obesity have increased the number of Canadians having knee replacements by more than 22 per cent in the past five years, with more than 75, 000 surgeries now performed each year.
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The U of A study calls into question the use of BMI as a determinant of patient outcomes for orthopedic surgery. For example, patients with higher BMIs are not eligible for knee replacement until they lower their BMI or lose weight. As a result, those patients spend more time on the waiting list, Godziuk said. Before the COVID-19 pandemic, wait times for knee surgery in Alberta averaged between 14 months and two years.
“Patients with a higher BMI wait even longer because they’re told to go try to lose weight first, so by the time they go to get surgery they’re maybe in worse condition than if they hadn’t tried that first.”
“We tell patients to go lose weight, to lower their BMI, but it can be harmful to have that blanket recommendation. What we’re suggesting is that maybe we don’t tell them to lose weight, but help them to prevent weight gain.” Kristine Godziuk, post-doctoral fellow in the Department of Occupational Therapy
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Weight bias is also at play. “It’s very challenging to lose weight and keep it off, ” said Godziuk. Obesity is not a lifestyle choice but a chronic condition that should not be measured by BMI, she said.
“We know that age is associated with increased surgical risk with knee replacement surgery, but we don’t tell people, ‘Well, you have to be younger than 70.’ We don’t do those cut-offs for age, but we do them for BMI, which ends up creating this bias in access to care.”
Not only does using BMI as a determinant limit surgical access, Godziuk said, but it can risk patients’ health, since short-term weight loss that can’t be maintained has few benefits, and could potentially be harmful.
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“We tell patients to go lose weight, to lower their BMI, but it can be harmful to have that blanket recommendation. What we’re suggesting is that maybe we don’t tell them to lose weight, but help them to prevent weight gain. Maybe that’s a better message to send to patients, and through that we can also support them to improve their body composition and overall health.”
Godziuk, who started her career as an exercise physiologist, said working in pediatric obesity helped her understand the need for more research in this area.
“I could see clinically, when I worked with adolescents, that BMI was a poor measure for them, and I know it’s a poor measure in adults. When we just rely on these simple metrics, I could see that there was this gap. And it’s so important from a rehabilitation perspective—to help patients live with osteoarthritis and manage it, including if they have obesity as well.”
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“We do such a good job of looking more in depth into all other areas of a person’s health, but to distil obesity down to BMI, we’re missing some information.
“We’re not saying that everyone with a high BMI should have knee surgery, but we’re calling into question the way it’s being assessed, that BMI alone is missing some things.”Rating the drugs in drug ads IBD and LGBTQ+: How it can affect sexual Mud runs: Dirty, challenging, next-level fun Wildfires: How to cope when smoke affects air quality and Ringworm: What to know and do warnings on exercise equipment: Should you worry? 3 simple swaps for better heart A hot weather plan is essential to staying y Young men with prostate cancer: Socioeconomic factors affect lifespan Talking to your doctor about your LGBTQ+ sex life
Come back when you've lost 40 pounds. That's something obese patients have heard often when being evaluated for a hip or knee replacement for severe arthritis. And sometimes the recommendation is to lose even more — 50, 75, or even 100 pounds… as if that's an easy or realistic prospect.
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As you might expect, patients hearing this often feel disappointed and disheartened. After all, most have already tried hard to lose weight with limited success. Their arthritis pain impairs their ability to exercise, and decreasing activity has contributed to their weight gain. So being told to lose significant weight before they can be considered for joint surgery sounds a lot like being told it's just not going to happen.
While the surgeon's recommendations may be disappointing, the rationale seems sound: people carrying a lot of excess weight have long been considered at higher risk for complications, and less likely to experience the profound pain relief expected from this major operation. Indeed, several studies describe higher rates of infections and dislocations and lower rates of good results after hip or knee replacement among the obese, especially the severely obese.
Importantly, many of these studies are more than a decade old, and newer studies are beginning to paint a different picture. A recent study on the risks and benefits of joint replacement among the obese sheds new — and positive — light on an issue that affects many thousands of people.
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Researchers analyzed the results of more than 5, 000 people having hip or knee replacement surgery, comparing pain and function before and six months after surgery. Here's what they found:
The authors conclude that obesity in itself should not be a deterrent to undergoing total joint replacement to relieve symptoms. However, the potential for more complications must be considered as well, something this study did not formally examine.
Given the high and rising rates of obesity and arthritis in this country, the results of this study will likely apply to many people. And they suggest that surgeons should change expectations about what surgery has to offer obese individuals with severe arthritis.
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While avoiding obesity in the first place is still preferable, there is increasing evidence that the benefits of joint replacement surgery are not limited to those who are lean. If this new research is confirmed by others, we may see fewer obese people turned down for joint replacement surgery in the future.
Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School.… See Full Bio
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