Clinical Orthopaedics and Related Research®

, Volume 471, Issue 11, pp 3523–3530 | Cite as

Bariatric Orthopaedics: Total Knee Arthroplasty in Super-obese Patients (BMI > 50 kg/m2). Survivorship and Complications

  • Qais Naziri
  • Kimona Issa
  • Arthur L. Malkani
  • Peter M. Bonutti
  • Steven F. Harwin
  • Michael A. Mont
Clinical Research



Some studies have suggested that patients who are super obese (BMI > 50 kg/m2) may have poorer outcomes and more frequent complications when undergoing TKA compared with those who have lower BMI, however, the literature on this is scant.


The purpose of this study was to compare a group of super-obese patients undergoing TKA with a matched group of patients with BMI less than 30 kg/m2 in terms of (1) implant survivorship, (2) complications, (3) functional parameters, and (4) intraoperative variables (including operative time and estimated blood loss).


One-hundred one knees in 95 patients (21 men, 74 women) who had a minimum BMI of 50 kg/m2 and who had undergone a primary TKA at one of the four high-volume institutions were compared with a group of patients who had a BMI less than 30 kg/m2 who were matched by age, gender, preoperative clinical scores, and mean followup. End points evaluated by chart review included implant survivorship, medical and surgical complications, functional parameters (The Knee Society outcome scores and ROM), and intraoperative variables at a mean followup of 62 months (range, 36–85 months).


With the numbers available, there were no differences in aseptic implant survivorship (94% versus 98%, p = 0.28), however, medical and surgical complication rates (14% versus 5%, OR: 3.1, 95% CI=1.07–8.9; p = 0.037) were significantly higher in the super-obese patients compared with the nonobese matching group, respectively. Super-obese patients also achieved lower mean Knee Society functional scores (82 versus 90 points, p = 0.004) and smaller gains in flexion arc ROM (14° versus 21°, p = 0.009); they also lost more blood during surgery and experienced longer surgical anesthesia times compared with the matched group, respectively.


With the numbers available, we could not identify what might have been modest differences in implant survivorship, however, complications were more frequent and functional outcomes were significantly lower in super-obese patients. Other studies similarly have found inferior outcomes in this challenging group of patients. Our data may be considered pilot data for future prospective studies with longer followup.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.


  1. 1.
    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. JBone Joint Surg Br. 2006;88:1321–1326.CrossRefGoogle Scholar
  2. 2.
    Amin AK, Patton JT, Cook RE, Brenkel IJ. Does obesity influence the clinical outcome at five years following total knee replacement for osteoarthritis? J Bone Joint Surg Br. 2006;88:335–340.PubMedGoogle Scholar
  3. 3.
    Baker P, Petheram T, Jameson S, Reed M, Gregg P, Deehan D. The association between body mass index and the outcomes of total knee arthroplasty. J Bone Joint Surg Am. 2012;94:1501–1508.PubMedCrossRefGoogle Scholar
  4. 4.
    Bin Abd Razak HR, Chong HC, Tan AH. Obesity does not imply poor outcomes in Asians after total knee arthroplasty. Clin Orthop Relat Res. 2013;471:1957–1963.PubMedCrossRefGoogle Scholar
  5. 5.
    Chalidis BE, Petsatodis G, Christodoulou AG, Christoforidis J, Papadopoulos PP, Pournaras J. Is obesity a contraindication for minimal invasive total knee replacement? A prospective randomized control trial. Obes Surg. 2010;20:1633–1641.PubMedCrossRefGoogle Scholar
  6. 6.
    Changulani M, Kalairajah Y, Peel T, Field RE. The relationship between obesity and the age at which hip and knee replacement is undertaken. J Bone Joint Surg Br. 2008;90:360–363.PubMedGoogle Scholar
  7. 7.
    Da Costa LA, Arora P, Garcia-Bailo B, Karmali M, El-Sohemy A, Badawi A. The association between obesity, cardiometabolic disease biomarkers, and innate immunity-related inflammation in Canadian adults. Diabetes Metab Syndr Obes. 2012;5:347–355.PubMedGoogle Scholar
  8. 8.
    Dalury DF, Tucker KK, Kelley TC. All-polyethylene tibial components in obese patients are associated with low failure at midterm followup. Clin Orthop Relat Res. 2012;470:117–124.PubMedCrossRefGoogle Scholar
  9. 9.
    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(6 suppl):89–94.PubMedCrossRefGoogle Scholar
  10. 10.
    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.PubMedCrossRefGoogle Scholar
  11. 11.
    Foran JR, Mont MA, Rajadhyaksha AD, Jones LC, Etienne G, Hungerford DS. Total knee arthroplasty in obese patients: a comparison with a matched control group. J Arthroplasty. 2004;19:817–824.PubMedCrossRefGoogle Scholar
  12. 12.
    Gadinsky NE, Ehrhardt JK, Urband C, Westrich GH. Effect of body mass index on range of motion and manipulation after total knee arthroplasty. J Arthroplasty. 2011;26:1194–1197.PubMedCrossRefGoogle Scholar
  13. 13.
    Gadinsky NE, Manuel JB, Lyman S, Westrich GH. Increased operating room time in patients with obesity during primary total knee arthroplasty: conflicts for scheduling. J Arthroplasty. 2012;27:1171–1176.PubMedCrossRefGoogle Scholar
  14. 14.
    Griffin FM, Scuderi GR, Insall JN, Colizza W. Total knee arthroplasty in patients who were obese with 10 years followup. Clin Orthop Relat Res. 1998;356:28–33.PubMedCrossRefGoogle Scholar
  15. 15.
    Higuera CA, Elsharkawy K, Klika AK, Brocone M, Barsoum WK. 2010 Mid-America Orthopaedic Association Physician in Training Award: predictors of early adverse outcomes after knee and hip arthroplasty in geriatric patients. Clin Orthop Relat Res. 2011;469:1391–1400.PubMedCrossRefGoogle Scholar
  16. 16.
    Issa K, Pivec R, Kapadia BH, Shah T, Harwin SF, Delanois RE, Mont MA. Does obesity affect the outcomes of primary total knee arthroplasty? J Knee Surg. 2013;26:89–94.PubMedCrossRefGoogle Scholar
  17. 17.
    Jacobs JJ, Mont MA, Bozic KJ, Della Valle CJ, Goodman SB, Lewis CG, Yates AC Jr, Boggio LN, Watters WC 3rd, Turkelson CM, Wies JL, Sluka P, Hitchcock K. American Academy of Orthopaedic Surgeons clinical practice guideline on: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Bone Joint Surg Am. 2012;94:746–747.PubMedCrossRefGoogle Scholar
  18. 18.
    James WP. WHO recognition of the global obesity epidemic. Int J Obes (Lond). 2008;32(suppl 7):S120–126.CrossRefGoogle Scholar
  19. 19.
    Jarvenpaa J, Kettunen J, Soininvaara T, Miettinen H, Kroger H. Obesity has a negative impact on clinical outcome after total knee arthroplasty. Scand J Surg. 2012;101:198–203.PubMedCrossRefGoogle Scholar
  20. 20.
    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.PubMedCrossRefGoogle Scholar
  21. 21.
    Krushell RJ, Fingeroth RJ. Primary total knee arthroplasty in morbidly obese patients: a 5- to 14-year follow-up study. J Arthroplasty. 2007;22(6 suppl 2):77–80.PubMedCrossRefGoogle Scholar
  22. 22.
    McElroy MJ, Pivec R, Issa K, Harwin SF, Mont MA. The effects of obesity and morbid obesity on outcomes in TKA. J Knee Surg. 2013;26:83–88.PubMedCrossRefGoogle Scholar
  23. 23.
    Members of 2007 and 2011 AAOS Guideline Development Work Groups on PE/VTED Prophylaxis, Mont M, Jacobs J, Lieberman J, Parvizi J, Lachiewicz P, Johanson N, Watters W. Preventing venous thromboembolic disease in patients undergoing elective total hip and knee arthroplasty. J Bone Joint Surg Am. 2012;94:673–674.Google Scholar
  24. 24.
    Mont MA, Mathur SK, Krackow KA, Loewy JW, Hungerford DS. Cementless total knee arthroplasty in obese patients: a comparison with a matched control group. J Arthroplasty. 1996;11:153–156.PubMedCrossRefGoogle Scholar
  25. 25.
    Namba RS, Paxton L, Fithian DC, Stone ML. Obesity and perioperative morbidity in total hip and total knee arthroplasty patients. J Arthroplasty. 2005;20(7 suppl 3):46–50.PubMedCrossRefGoogle Scholar
  26. 26.
    Nicholls AS, Kiran A, Javaid MK, Hart DJ, Spector TD, Carr AJ, Arden NK. Change in body mass index during middle age affects risk of total knee arthoplasty due to osteoarthritis: a 19-year prospective study of 1003 women. Knee. 2012;19:316–319.PubMedCrossRefGoogle Scholar
  27. 27.
    Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity in the United States, 2009–2010. NCHS Data Brief No 82. Hyattsville, MD: National Center for Health Statistics; 2012.Google Scholar
  28. 28.
    Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, Mont MA, Wongworawat MD, Zalavras CG. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469:2992–2994.PubMedCrossRefGoogle Scholar
  29. 29.
    Raphael IJ, Parmar M, Mehrganpour N, Sharkey PF, Parvizi J. Obesity and operative time in primary total joint arthroplasty. J Knee Surg. 2013;26:95–99.PubMedCrossRefGoogle Scholar
  30. 30.
    Ritter MA, Davis KE, Meding JB, Pierson JL, Berend ME, Malinzak RA. The effect of alignment and BMI on failure of total knee replacement. J Bone Joint Surg Am. 2011;93:1588–1596.PubMedCrossRefGoogle Scholar
  31. 31.
    Schwarzkopf R, Thompson SL, Adwar SJ, Liublinska V, Slover JD. Postoperative complication rates in the “super-obese” hip and knee arthroplasty population. J Arthroplasty. 2012;27:397–401.PubMedCrossRefGoogle Scholar
  32. 32.
    Sherwin R, Jastreboff AM. Year in diabetes 2012: the diabetes tsunami. J Clin Endocrinol Metab. 2012;97:4293–4301.PubMedCrossRefGoogle Scholar
  33. 33.
    Spicer DD, Pomeroy DL, Badenhausen WE, Schaper LA Jr, Curry JI, Suthers KE, Smith MW. Body mass index as a predictor of outcome in total knee replacement. Int Orthop. 2001;25:246–249.PubMedCrossRefGoogle Scholar
  34. 34.
    Suleiman LI, Ortega G, Ong’uti SK, Gonzalez DO, Tran DD, Onyike A, Turner PL, Fullum TM. Does BMI affect perioperative complications following total knee and hip arthroplasty? J Surg Res. 2012;174:7–11.PubMedCrossRefGoogle Scholar
  35. 35.
    Vasarhelyi EM, MacDonald SJ. The influence of obesity on total joint arthroplasty. J Bone Joint Surg Br. 2012;94(11 suppl A):100–102.PubMedGoogle Scholar
  36. 36.
    Vazquez-Vela Johnson G, Worland RL, Keenan J, Norambuena N. Patient demographics as a predictor of the ten-year survival rate in primary total knee replacement. J Bone Joint Surg Br. 2003;85:52–56.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Qais Naziri
    • 1
  • Kimona Issa
    • 1
  • Arthur L. Malkani
    • 2
  • Peter M. Bonutti
    • 3
  • Steven F. Harwin
    • 4
  • Michael A. Mont
    • 1
  1. 1.Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and ReconstructionSinai Hospital of BaltimoreBaltimoreUSA
  2. 2.The University of Louisville Department of Orthopaedic SurgeryLouisvilleUSA
  3. 3.Bonutti ClinicEffinghamUSA
  4. 4.Adult Reconstructive Surgery ServiceBeth Israel HospitalNew YorkUSA

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