Safety of bilateral total knee arthroplasty in morbidly obese patients.
Article Safety of Bilateral Total Knee Arthroplasty in Morbidly Obese Patients
Failure rate in obese patients is higher than this of the normal population. Complication rate also is higher. The failure sometimes is iatrogenic because of mal-position of the tibial tray (it is noted that due to limited ability to adequately expose the knee (soft tissues are retracted laterally) the lateral compartment is not visualised and the tibial tray is positioned in varus). This is increasing the shearing forces and the knee is painful, as it will be expected and at the and it is failing quicker that the mean expected time. Also failure is following the excessive loading of the components. In case of miscalculation of the tibial component's size (and a smaller component is placed) this has the tendency to sink within the bone. Due to these and also more other complications (due to comorbidities the patients have; some of them can lead to infection and subsequent revision) there are voices of concern and in some places (mainly under the NHS) the limit of a patient who will be allowed to have a joint replacement is the BMI of 34.
So, is it safe for high BMI patients to have a TKR?
The answer is Yes, only if the surgeon is understanding the limitations, be prepared, explain all potential complications to patient and be ready to embark to the operation.
Raju,
At some level, one has to recognize the aspect of failure of the original knee having to do with morbid obesity. As George points out, it can be done but it seems an excellent idea to educate (and somehow motivate) the person to safely lose excess weight. Otherwise, it would be analogous to giving a new liver to an alcoholic who continues with his customary drinking practices.
It is sort of a catch 22... many surgeons and institutions end up with their own experience based guidelines or decide on a case by case basis.
The following article and many similar ones in literature may give you some idea, just in case if you haven't already seen them:
The effects of obesity and morbid obesity on outcomes in TKA.
J Knee Surg. 2013 Apr;26(2):83-8. doi: 10.1055/s-0033-1341407. Epub 2013 Mar 11.
http://www.ncbi.nlm.nih.gov/pubmed/23479424
[In a private hospital setting, where the hospital doesn't have to be concerned about getting the bills paid, I suppose the age old wisdom applies... it is fine to perform the procedure if a patient insists on it, understands the ramifications and has the ability to pay the cash. The first 2 stipulations may have some flexibility in it. ;) ]
Coincidently more the BMI, more are the chances of having severe knee OA, requiring TKA. Also, it is a fact these morbid obese pts find it impossible to loose weight (easier said than done!). Hence, it is a challenging situation for the patients, family and the doctors to decide about the cure of their pain. If they are unable to lose weight or wanted to undergo bariatric surgery, should we leave them at the mercy of God or take an informed consent and do their TKA?
In UK there is the limit of BMI 50 that they are offered bariatric surgery. The question is patients between BMI 34-50. What do they do? They either go on programmes of not gravitational exercises and diet, or they undergo the bariatric on their own expenses. On the other hand if patients understand the limitations of the procedure and they consent to it but with the promise that they undergo special treatment postoperatively, which will be wise to be pre-organised(in other words are motivated) than surgery can be performed. In my experience these patients manage to loose weight and they are very grateful.
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