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appear to worsen outcomes, although it may negatively impact patients’ pain, disability, productivity and income41 . Recovery and rehabilitation after TJA Recovery after TKA is influenced by many factors, and evidence on the impact of obesity on recovery is controversial78 . Strength, age, range of motion, and pain seem to have the strongest relationship with recovery, whereas obesity, timing of the surgery, and sex (male or female) have less influence78 . Further research is needed to determine if specific treatment modalities improve rehabilitation outcomes after TKA in patients with obesity64. Physical activity programs after TJA were recommended for patients with obesity to increase energy expenditure and assist with weight loss79 . While there are concerns about the longevity of the prosthetic implant, low and moderate physical activity was still advised79 . Revision after TJA With currently increased rates of TJA, it is expected that rates of revision surgeries will also increase80 . Evidence suggests that medium to long term survival of the prosthesis is poorer in patients with obesity, but this may be related to earlier age when arthroplasty is needed (often 10 years earlier)80. Early prosthetic failure, within 2 years of arthroplasty, is often related to infection and instability, whereas mechanical wear and loosening is associated with later failure80 . Revision surgery is often more complex, with higher associated healthcare costs80 . Weight loss prior to TJA Even though many authors recommend that patients with obesity lose weight before TJA45,46,71 , there is little evidence on safety and effectiveness to support this recommendation74. In a systematic review, Lui et at52 found limited evidence to support non-surgical, nonpharmacological weight loss on TJA outcomes. They found only 2 retrospective cohort studies (by the same author), and 2 randomized controlled trial abstracts (no full text available) 52 . In the two cohort studies (where weight loss was ≥5% of body weight lost and maintained in the year prior to surgery, but no information on methods used for weight loss), weight loss was associated with either no difference or increased odds of deep infection and 90 day readmission with TJA 52. This may be related to inadvertent malnourishment related to weight loss52 . In 2016 the AACE/ACE clinical practice guidelines removed previous recommendation for weight loss prior to TJA due to gaps in the current evidence42 . Optimization of comorbidities 15 Bone and Joint Health Strategic Clinical Network prior to TJA may be more important than weight loss47, as malnourishment or skeletal muscle loss associated with weight loss may increase surgical risk52 . The impact of bariatric surgery before TKA on surgical outcomes was investigated by Smith et al51 in 2016. Meta-analysis revealed no significant difference in superficial infection, deep infection, pulmonary embolism, revision surgery (up to 14 years post TJA) or mortality when comparing those who had bariatric surgery prior to TJA to those who did not51. While reduced infection rates were seen in individuals who had bariatric surgery, the quality of evidence was low and studies were underpowered51 . Additionally, the long wait times for bariatric surgery and extended post-bariatric surgery recovery would delay TKA several years, which can be a long time to wait for individuals with severe end stage osteoarthritis66 . Currently there is insufficient evidence to recommend bariatric surgery before arthroplasty33,51,73,81 . Weight loss after TJA Inacio et al53 conducted a systematic review to examine weight loss after TJA53 . The evidence is inconsistent, but the small sample sizes and low methodological quality of studies limit definitive conclusions. Currently, there is inconclusive evidence that weight or body composition increases, decreases or remains stable after TJA53 . Limitations in current evidence Osteoarthritis literature on TJA contains few prospective controlled trials, and most conclusions are based on retrospective cross-sectional or cohort studies5 . Conducting systematic reviews and meta analyses has been difficult or prevented by heterogeneity in the literature74. Many studies have used different outcomes or report them differently, which prevents effective comparisons or pooling of results. Conflicting evidence has been reported regarding the impact of obesity. Differences in cohort sample sizes (ie. in Liu et al48, some studies had 50 THAs compared to others with 2495 THAs), low event rates, or low power from the small sample sizes may be influencing results47,65,82 . When examining revision rates, length of follow up differed significantly between studies (in Liu et al48, follow-up ranged from 3 months to 18 years48), again making comparisons difficult. Many studies have only defined BMI categorically (BMI above 30 kg/m2 compared to BMI below 30 kg/m2 ), or used different BMI cut-offs to define obesity (i.e. BMI of 27, 30, or 35 kg/m2 ) 47. It is recommended that future studies stratify by BMI or treat it as a continuous variable, which may help clarify the incidence and relationship with perioperative risk44,65,74,82. Most importantly, studies have not always reported or sub-classified subjects by comorbidities such as diabetes, hypertension, cardiac disease, or sleep apnea, each of which independently impacts
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