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undergone bariatric surgery also seem to contribute to pain relief.42,43 Several studies have investigated weight loss as a treatment for OA. In 1990, McGoey et al44 conducted what could have been the first prospective trial to study the role of weight loss in the relief of musculoskeletal pain. Unfortunately, a control group of patients that failed to lose weight never materialised. They studied 105 patients who underwent vertical-banded gastroplasty, which involves converting the stomach from a large reservoir to a narrow conduit with lines of staples and a non-expandable mesh collar at the lower end of the gastric tube.45 Post-operatively, patients can only eat small, well-chewed meals, and weight loss is accomplished via limited intake. One year 436 M. S. SRIDHAR, C. D. JARRETT, J. W. XEROGEANES, S. A. LABIB THE JOURNAL OF BONE AND JOINT SURGERY after surgery, with a mean weight loss of 97 lbs, 93 of 105 patients (89%) had complete relief of pain in one or more joints.44 Moreover, of 60 (57%) who had knee pain before surgery, only 15 (14%) had knee pain at one year post-operatively. Interestingly, there was no significant difference in pain relief between those patients who lost a moderate (< 60 lbs) amount of weight and those who lost a greater amount (> 99 lbs).44 More recently, Abu-Abeid et al46 prospectively evaluated the effect of bariatric surgery on patients with knee pain but without a diagnosis of OA. They concluded that surgicallyinduced weight loss is an effective, rapid, and dependable means of reversing the radiological signs of early changes associated with OA. This study emphasised the potentially reversible pathology of early degenerative knee pain. Our unpublished pilot study followed ten morbidly obese patients with knee pain and radiological OA before and after bariatric surgery for one year. The mean weight loss was 51 lbs (22 to 103). Of these, seven underwent laparoscopic adjustable gastric banding (Fig. 1a), two underwent laparoscopic Roux-en-Y gastric bypass (Fig. 1b), and one underwent a laparoscopic vertical sleeve gastrectomy (Fig. 1c). Although improvement was found in the mean visual analogue scale pain scores, Western Ontario and McMaster University Osteoarthritis Index physical function and pain sub-scores47 and the mean Short Form-12 score,48 the mean International Knee Documentation Committee scores49 deteriorated. These preliminary data suggest that surgically-assisted weight loss may result in an improvement in knee pain, but there appears to be irreparable damage from being morbidly obese that limits any improvement in knee pain despite significant weight loss. Unfortunately, assessment of the radiological change was not a part of our investigation. Parvizi, Trousdale and Sarr50 reviewed 12 TKRs in patients who had undergone pre-operative bariatric surgery. When assessed with eight other patients who had undergone a total hip replacement (THR), the mean reduction in BMI was from 49 to 29, and the mean time from bariatric surgery to joint replacement was 23 months. In the TKR subgroup, the cumulative Knee Society scores (KSS)51 improved significantly post-operatively and no patient required revision at a mean followup of 3.7 years (2 to 11). The authors stated that morbidly obese individuals with severe degenerative joint disease, who are deemed to be unsuitable for a joint replacement because of their weight, should be considered for bariatric surgery. Although they only had a small number of patients with relatively short follow-up (particularly important relative to the development of aseptic loosening and need for implant revision), they remained confident that joint replacement after surgical treatment for obesity resulted in an excellent outcome and had an acceptable complication rate.50 Arthroscopy of the knee. Although there are no randomised controlled trials investigating the effects of BMI on cartilage resurfacing procedures, obesity is certainly a concern for most surgeons. These procedures include Fig. 1a Diagrams illustrating the surgical options for weight loss, a) Gastric banding: an adjustable silicone band is placed around the upper stomach. Patients feel full more quickly and thereby eat less. The surgery is reversible when medically indicated. b) Gastric bypass: this procedure reduces stomach size and diverts the passage of food through the small intestine to limit digestion. As in gastric banding, patients feel full after eating less food and food that is consumed has less opportunity to be absorbed. c) Sleeve gastrectomy: typically, 75% of the stomach is resected. The remaining, smaller stomach is reshaped into the form of a sleeve. Patients experience normal digestion and report feeling full more quickly and having less hunger. (Courtesy of Emory Bariatric Center). Fig. 1b Fig. 1c OBESITY AND SYMPTOMATIC OSTEOARTHRITIS OF THE KNEE 437 VOL. 94-B, No. 4, APRIL 2012 microfracture, osteochondral autograft transport, autologous chondrocyte implantation and osteochondral allografting.52 Arthroscopy of the knee in the morbidly obese patient is technically demanding. Berg53 stated that because it is difficult to palpate the bony landmarks, a greater number of arthroscopy portals were needed and larger knees cannot be accommodated by standard-sized leg holders and tourniquets. Additionally, in the morbidly
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