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surgical infection and complication rates65,74 . For example, diabetes may double the infection risk independent of obesity81,83. This inability to account for comorbidities is identified as a limitation in several of the systematic reviews44,46,47,75 . 16 Bone and Joint Health Strategic Clinical Network Summary of key knowledge synthesis points for osteoarthritis patients with obesity Non-surgical treatment (conservative management) · Evidence for treatment interventions that combine diet and physical activity. · Limited evidence of specific physical activities recommended for patients with osteoarthritis and obesity. · Recommendations of weight loss of greater or equivalent to 5-10% of body weight to impact osteoarthritis related symptoms, however weight loss and maintenance of weight loss is challenging, particularly in those with mobility limitations. · Limited evidence to recommend bariatric surgery as a treatment for osteoarthritisrelated pain and function. Surgical treatment · Evidence of increased infection rates in TKA with BMI greater than 30 kg/m2 , with even higher rates when BMI is greater than 40 kg/m2 . · Some evidence of increased infection and dislocation rates in THA with BMI greater than 30 kg/m2 .* · Conflicting evidence on increased revision rates. · While surgical risk is higher when BMI is above 30 kg/m2 , there is little support for using an absolute value of BMI as a TJA-eligibility cut-off. The lack of support is related to limitations and conflicting results in underlying research, and clear evidence that patients with obesity benefit from this procedure. · Limited evidence that weight loss in the year prior to TJA reduces the risk of infection; weight loss greater than 5% of body weight may either have no impact, or may increase the risk of deep surgical infection or 90-day hospital readmission after surgery. Both surgical and non-surgical · Weight loss can result in the loss of skeletal muscle in addition to fat, and this wouldn’t be apparent by looking at change in BMI. Adults with osteoarthritis are already at risk of having lower skeletal muscle and strength due to aging and pain-related reduced physical activity. Weight loss could increase the risk of mobility limitations and sarcopenic obesity by further reducing skeletal muscle. Body composition may be a more important clinical measure than BMI. * Although not included in this synthesis due to later publication date, clinical guidelines published March 2017 report that patient satisfaction, functional improvement and pain reduction after THA is similar in patients with and without obesity, with limited evidence on increased infection and dislocation rates84 . 17 Bone and Joint Health Strategic Clinical Network Knowledge gaps The results of this knowledge synthesis indicate that there are several issues and knowledge gaps regarding treatment recommendations for adults with osteoarthritis and obesity. In addition to lack of knowledge, the generally low/poor quality of evidence in this area makes it difficult to draw definitive conclusions that would be useful for decision making at the patient, clinician and system levels. More research is needed to clearly delineate the aspects of increased surgical risk in patients with obesity. The literature is also lacking in specific recommendations for non-surgical management, and information from the perspective of patients who have both osteoarthritis and obesity, which is imperative when making recommendations to change and improve clinical practice. Considerations for moving forward in Alberta The BJH SCN recommends workshop stakeholders consider the following issues when determining strategies for moving forward in the treatment of osteoarthritis in patients with obesity in Alberta: · Clinical practice guidelines recommend health care practitioners provide weight loss advice for patients with overweight or obesity, yet many practitioners may not have training in evidence-based weight management treatment recommendations. Improving access to education for practitioners or increasing access and referrals to weight management services may be needed. · Development of integrated models of care that treat osteoarthritis and obesity concurrently may be beneficial. As diet and physical activity are the cornerstones of both obesity and osteoarthritis treatment recommendations, provision of interventions or services that address both conditions together may be more efficient. · Prior to recommending weight loss, practitioners should consider the challenges of long term weight loss and maintenance and whether losing weight could be harmful for a patient (i.e. older individuals, or those at risk of having low muscle mass or muscle weakness). Additionally, providers should consider the patients previous attempts at weight management before making recommendations. · Consideration of the patients’ perspective on preferred weight loss treatments must be incorporated, as patients may not be preferential to having a surgical intervention (bariatric surgery) in preparation for another surgical intervention (arthroplasty). · There is a lack of follow-up information on the health trajectory of patients who are not considered appropriate for TJA due to obesity severity or associated comorbidities. Consideration of appropriate treatment strategies for patients who are unable to have surgery may be
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