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complications in patients with obesity include avulsion of the medial collateral ligament related to knee hyperflexion, which may be associated with limited ROM or surgical technique45,66 . If limb adiposity limits knee flexion to less than 60 degrees, there may not be access to insert the tibial component of the knee prosthesis66 . Patients whose knees are difficult to access due to severe adiposity or an abdominal pannus may require bariatric intervention66 . Assessing suitability for total joint arthroplasty (TJA) The best risk stratification method for TJA in patients with obesity is unclear73. Current practice relies on clinical judgement33, considering disease severity and individual characteristics that may influence surgical results, such as age, BMI, psychosocial health, and comorbid conditions33 . Establishing an absolute value of BMI as a cut-off for TJA has been suggested in the literature46,48,74 (particularly for those with a BMI greater than 40kg/m2 ) 46,74 . Yet identification of high risk versus low risk patients is unclear from current evidence46,75, so a BMI cut-off remains controversial65 . BMI cut-offs may limit access to important surgery that improves quality of life, creating a bias for patients with obesity73,76 . The positives of improved function, quality of life and patient satisfaction may outweigh any increased risk65. These risks and advantages need to be discussed with each individual patient44,75 . 13 Bone and Joint Health Strategic Clinical Network The impact of not doing surgery should also be considered. If surgery is not provided, the patient’s health may deteriorate, worsening physical function, quality of life, and independence. This can increase the burden on patients, their families, and society as a whole relative to increased healthcare costs and loss of productivity33 . A 2016 study examined the economic costs of knee and hip arthroplasty in patients with obesity77, and while BMI was associated with higher hospital-related treatment costs, rehabilitation, outpatient and ambulatory care, individual patient costs, and societal costs were not considered. Total hip arthroplasty (THA) Two systematic reviews and meta-analyses examined impact of obesity on THA outcomes47,48 . Liu et al48 compared BMI groups (BMI less than 30 kg/m2 , between 30 and 40 kg/m2 , and greater than 40 kg/m2 ) and reported higher overall complications, dislocations, and deep infections after THA in those with obesity, and longer operating times but no difference in length of stay48 . The higher complication rates in those with obesity may be related to the longer surgery times, which could increase exposure and soft tissue damage48 . Haverkamp et al47 compared groups with a BMI less than 30 kg/m2 to those with a BMI greater than 30 kg/m2 , and found higher rates of aseptic loosening, infection, and venous thromboembolism in those with a BMI above 30 kg/m2 . The meta-analysis was unable to compare patient reported functional outcomes due to heterogeneity47 . The data included in these two reviews were not adjusted for comorbidities, which could impact the results47,48 . Total knee arthroplasty (TKA) Five studies conducted systematic reviews to examine the impact of obesity on TKA outcomes44–46,72,75. Two44,46 included meta-analyses. Kerkhoffs et al44 compared BMI groups (BMI less than 30 kg/m2 to greater than 30 kg/m2 ) and found increased rates of deep and superficial infection and revision in those with a BMI greater than 30 kg/m2 , but no difference in venous thromboembolism or pulmonary embolism44 . Si et al46 compared BMI groups (BMI less than 30 kg/m2 to greater than 30 kg/m2 , greater than 35 kg/m2 , and greater than 40 kg/m2 ) and found increased rates of revision and superficial infection in those with BMI greater than 30 kg/m2 compared to less than 30 kg/m2 . With a BMI greater than 40 kg/m2 , there were higher rates of overall infections, superficial and deep infections, and deep vein thrombosis compared to BMI less than 30 kg/m2 . Those with BMI greater than 40 kg/m2 did not have higher rates of revision after 5 years compared to BMI less than 30 kg/m2 . Three of the studies examined the impact of morbid obesity on TKA outcomes45,72,75 . Samson et al45 found 3-9 times greater rates of deep infection with BMI greater than 40 kg/m2 compared to less than 30 kg/m2 , but comparable improvements in Knee Society Scores. Vaishya et al72 compared BMI less than 30 kg/m2 to greater than 40 kg/m2 , and found a BMI greater than 40 kg/m2 was associated with higher rates of overall complications and superficial infections, but no difference in deep infection rates, prosthetic survival, and Knee Society Scores. McElroy et 14 Bone and Joint Health Strategic Clinical Network al 75 compared BMI groups 30-39 kg/m2 and 40-49.9 kg/m2 against BMI less than 30 kg/m2 . Implant failure and perioperative complications were higher in BMI 40-49.9 kg/m2 , and this group had poorer Knee Society Scores after surgery compared to BMI less than 30 kg/m2 . Several of the systematic reviews indicated that results may have been impacted by a lack of control for confounding comorbidities44,46,75 . The AAOS clinical guidelines reported that patients with obesity (defined with BMI) have poorer TKA outcomes41, and a short term delay in TKA (up to 8 months to provide time for weight loss) does not
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