Abstract
Background
The importance of morbid obesity as a risk factor for complications after total knee arthroplasty (TKA) continues to be debated. Obesity is rarely an isolated diagnosis and tends to cluster with other comorbidities that may independently lead to increased risk and confound outcomes. It is unknown whether morbid obesity independently affects postoperative complications and resource use after TKA.
Questions/purposes
The purpose of this study was to determine whether morbid obesity is an independent risk factor for inpatient postoperative complications, mortality, and increased resource use in patients undergoing primary TKA.
Methods
The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) database was used to identify patients undergoing primary TKA from October 2005 to December 2008. Morbid obesity (body mass index ≥ 40 kg/m2) was determined using International Classification of Diseases, 9th Revision, Clinical Modification codes. In-hospital postoperative complications, mortality, costs, and disposition for morbidly obese patients were compared with nonobese patients. To control for potential confounders and comorbid conditions, each morbidly obese patient was matched to a nonobese patient using age, sex, and all 28 comorbid-defined elements in the NIS database based on the Elixhauser Comorbidity Index. Of 1,777,068 primary TKAs, 98,410 (5.5%) patients were categorized as morbidly obese. Of these, 90,045 patients (91%) were able to be matched one-to-one to a nonobese patient for the adjusted analysis.
Results
Morbidly obese patients had a higher risk of postoperative in-hospital infection (0.24% versus 0.17%; odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1–1.7; p = 0.001), wound dehiscence (0.11% versus 0.08%; OR, 1.3; 95% CI, 1.0–1.7; p = 0.28), and genitourinary-related complications (0.60% versus 0.44%; OR, 1.3; 95% CI, 1.1–1.5; p < 0.001). There was no increase in the prevalence of cardiovascular or thromboembolic-related complications. Morbidly obese patients were at higher risk of in-hospital death after primary TKA compared with nonobese patients (0.08% versus 0.02%; OR, 3.2; 95% CI, 2.0–5.2; p < 0.001). Total hospital costs (USD 15,174 versus USD 14,715, p < 0.001), length of stay (3.6 days versus 3.5 days, p < 0.001), and rate of discharge to a facility (40% versus 30%, p < 0.001) were all higher in morbidly obese patients.
Conclusions
Morbid obesity appears to be independently associated with a higher risk for a small number of select in-hospital postoperative complications and mortality after matching for comorbid medical conditions linked to obesity. However, the independent impact of morbid obesity appears to be fairly modest, and morbid obesity did not appear to be an independent risk factor for many systemic complications. Continued research is necessary to identify the influence of associated comorbidities on early postoperative complications in morbidly obese patients after TKA.
Level of Evidence
Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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References
Abdel MP, Ast MP, Lee YY, Lyman S, Gonzalez Della Valle A. All-cause in-hospital complications and urinary tract infections increased in obese patients undergoing total knee arthroplasty. J Arthroplasty. 2014 Feb 12. pii: S0883-5403(14)00105-3. doi: 10.1016/j.arth.2014.02.013. [Epub ahead of print]
Amin AK, Clayton RA, Patton JT, Gaston M, Cook RE, Brenkel IJ. Total knee replacement in morbidly obese patients. Results of a prospective, matched study. J Bone Joint Surg Br. 2006;88:1321–1326.
Batsis JA, Naessens JM, Keegan MT, Huddleston PM, Wagie AE, Huddleston JM. Body mass index and the impact on hospital resource use in patients undergoing total knee arthroplasty. J Arthroplasty. 2010;25:1250–1257.e1251.
Blackwell M, Iacus S, King G. CEM: coarsened exact matching in STATA. Stata J. 2009;9:525–546.
Bordini B, Stea S, Cremonini S, Viceconti M, De Palma R, Toni A. Relationship between obesity and early failure of total knee prostheses. BMC Musculoskelet Disord. 2009;10:29.
Bozic KJ, Bashyal RK, Anthony SG, Chiu V, Shulman B, Rubash HE. Is administratively coded comorbidity and complication data in total joint arthroplasty valid? Clin Orthop Relat Res. 2013;471:201–205.
Bozic KJ, Kurtz SM, Lau E, Ong K, Chiu V, Vail TP, Rubash HE, Berry DJ. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010;468:45–51.
Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91:128–133.
Chesney D, Sales J, Elton R, Brenkel IJ. Infection after knee arthroplasty a prospective study of 1509 cases. J Arthroplasty. 2008;23:355–359.
D’Apuzzo MR, Browne JA. Obstructive sleep apnea as a risk factor for postoperative complications after revision joint arthroplasty. J Arthroplasty. 2012;27:95–98.
Dewan A, Bertolusso R, Karastinos A, Conditt M, Noble PC, Parsley BS. Implant durability and knee function after total knee arthroplasty in the morbidly obese patient. J Arthroplasty. 2009;24:89–94, 94.e81–83.
Dowsey MM, Choong PF. Obese diabetic patients are at substantial risk for deep infection after primary TKA. Clin Orthop Relat Res. 2009;467:1577–1581.
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36:8–27.
Fehring TK, Odum SM, Griffin WL, Mason JB, McCoy TH. The obesity epidemic: its effect on total joint arthroplasty. J Arthroplasty. 2007;22:71–76.
Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA. 2012;307:491–497.
Friedman RJ, Hess S, Berkowitz SD, Homering M. Complication rates after hip or knee arthroplasty in morbidly obese patients. Clin Orthop Relat Res. 2013;471:3358–3366.
Gandhi K, Viscusi ER, Schwenk ES, Pulido L, Parvizi J. Quantifying cardiovascular risks in patients with metabolic syndrome undergoing total joint arthroplasty. J Arthroplasty. 2012;27:514–519.
Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc. 2001;76:897–905.
Healthcare Cost and Utilization Project (HCUP). Introduction to the HCUP Nationwide Inpatient Sample (NIS) 2005. Rockville, MD, USA: Agency for Healthcare Quality and Research; 2007.
Iacus S, King G, Porro G. CEM: software for coarsened exact matching. J Stat Softw. 2009;30:1–27.
Jamsen E, Nevalainen P, Eskelinen A, Huotari K, Kalliovalkama J, Moilanen T. Obesity, diabetes, and preoperative hyperglycemia as predictors of periprosthetic joint infection: a single-center analysis of 7181 primary hip and knee replacements for osteoarthritis. J Bone Joint Surg Am. 2012;94:e101.
Jarvenpaa J, Kettunen J, Kroger H, Miettinen H. Obesity may impair the early outcome of total knee arthroplasty. Scand J Surg. 2010;99:45–49.
Jiganti JJ, Goldstein WM, Williams CS. A comparison of the perioperative morbidity in total joint arthroplasty in the obese and nonobese patient. Clin Orthop Relat Res. 1993;289:175–179.
Kerkhoffs GM, Servien E, Dunn W, Dahm D, Bramer JA, Haverkamp D. The influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review. J Bone Joint Surg Am. 2012;94:1839–1844.
Kim SH. Morbid obesity and excessive hospital resource consumption for unilateral primary hip and knee arthroplasty. J Arthroplasty. 2010;25:1258–1266.
Krushell RJ, Fingeroth RJ. Primary Total knee arthroplasty in morbidly obese patients: a 5- to 14-year follow-up study. J Arthroplasty. 2007;22:77–80.
Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty. 2009;24:84–88.
Mantilla CB, Horlocker TT, Schroeder DR, Berry DJ, Brown DL. Risk factors for clinically relevant pulmonary embolism and deep venous thrombosis in patients undergoing primary hip or knee arthroplasty. Anesthesiology. 2003;99:552–560; discussion 555A.
Miric A, Lim M, Kahn B, Rozenthal T, Bombick D, Sculco TP. Perioperative morbidity following total knee arthroplasty among obese patients. J Knee Surg. 2002;15:77–83.
Namba RS, Paxton L, Fithian DC, Stone ML. Obesity and perioperative morbidity in total hip and total knee arthroplasty patients. J Arthroplasty. 2005;20:46–50.
Odum SM, Springer BD, Dennos AC, Fehring TK. National obesity trends in total knee arthroplasty. J Arthroplasty. 2013;28(Suppl):148–151.
Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am. 2007;89:33–38.
Peersman G, Laskin R, Davis J, Peterson M. Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res. 2001;392:15–23.
Pottie P, Presle N, Terlain B, Netter P, Mainard D, Berenbaum F. Obesity and osteoarthritis: more complex than predicted! Ann Rheum Dis. 2006;65:1403–1405.
Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466:1710–1715.
Samson AJ, Mercer GE, Campbell DG. Total knee replacement in the morbidly obese: a literature review. ANZ J Surg. 2010;80:595–599.
Vgontzas AN, Bixler EO, Chrousos GP. Sleep apnea is a manifestation of the metabolic syndrome. Sleep Med Rev. 2005;9:211–224.
Winiarsky R, Barth P, Lotke P. Total knee arthroplasty in morbidly obese patients. J Bone Joint Surg Am. 1998;80:1770–1774.
Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee. Obesity and total joint arthroplasty: a literature based review. J Arthroplasty. 2013;28:714–721.
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D’Apuzzo, M.R., Novicoff, W.M. & Browne, J.A. The John Insall Award: Morbid Obesity Independently Impacts Complications, Mortality, and Resource Use After TKA. Clin Orthop Relat Res 473, 57–63 (2015). https://doi.org/10.1007/s11999-014-3668-9
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DOI: https://doi.org/10.1007/s11999-014-3668-9