Monday, November 25, 2013

BMI Does Not Affect Outcomes in Knee-Replacement Surgery

sharma-obesity-knee-arthtoplasty2One of the most pervasive “myths” amongst orthopaedic surgeons is that higher BMI is a contraindication to knee-replacement surgery.

Regular readers, however, will perhaps previous posts on this issue, suggesting that BMI is largely irrelevant in terms of outcomes and benefits for obese patients requiring knee replacements.

This previous finding is further supported by a new paper by David Murray and colleagues from The University of Oxford, UK, published in KNEE.

The researchers prospectively examined the impact of BMI on failure rate and clinical outcomes of 2,438 unicompartmental knee replacements in 378 patients with a BMI less than 25, 856 patients with a BMI 25 to 30, 712 patients with a BMI 30 to 35, 286 patients with a BMI 35 to 40, 126 patients with a BMI 40 to 45 and 80 patients with BMI greater than 45.

At a mean follow-up of 5 years (range 1–12 years) there was no significant difference in the Objective American Knee Society Score between BMI groups.

Although there was a slight trend to decreasing post-operative function scores with increasing BMI, patients with higher BMI had lower scores prior to surgery. Thus, overall higher BMIs were associated with a greater change in functional scores.

Thus, this study, further confirms the notion that obese individual have as much (if not more) to benefit from knee replacement surgery with little evidence that initial BMI adversely affects outcomes.

For clinicians this finding means that there is little evidence to deny knee replacement surgery to individuals with higher BMI levels or require that these patients lose weight prior to surgery.

If you have experience (positive or negative) with knee replacement surgery in overweight and obese patients, I’d like to hear from you.

@DrSharma
Edmonton, AB

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Monday, May 27, 2013

Osteoarthritis and Heart Disease

sharma-obesity-knee-osteoarthritis1Given that osteoarthritis often severely limits physical activity, I have long suspected that individuals with joint problems should be at higher risk of cardiovascular disease.

Now, Mushfiqur Rahman and colleagues from the University of British Columbia, in a paper published in BMJ Open report a rather strong relationship between osteoarthritis and cardiovascular disease.

Based on cross-sectional data from the nationally representative Canadian Community Health Survey, about 40,000 self-reported subjects with osteoarthritis were matched 1-1 by participants without joint problems of similar age, sex and CCHS cycles.

After adjusting for sociodemographic status, obesity, physical activity, smoking status, fruit and vegetable consumption, medication use, diabetes, hypertension and chronic obstructive pulmonary disease, individuals with osteoarthritis were significantly more likely to have angina and congestive heart failure (in both men and women), and for myocardial infarction (in women).

As this risk remained elevated even after adjusting for risk factors including physical activity, the question remains whether or not osteoarthritis and heart disease may in fact be causally linked by other mechanisms including chronic systemic inflammation.

As clinicians, we should certainly be aware to screen our patients with osteoarthritis for the presence of additional cardiometabolic risk factors and occult heart disease.

AMS
Frankfurt, Germany

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Friday, April 19, 2013

Obesity is Associated With Lower Risk of Hip Fractures

sharma-obesity-pelvisThere is no shortage of health conditions that are either directly or indirectly related to excess body fat. Thus, it is of particular interest, when researchers find conditions for which the risk may actually be lower in obese individuals.

One such condition is hip fractures.

Thus, a meta-analysis by Tang and colleagues from Shanghai, published in PLoS One, demonstrates a substantially lower risk of hip fractures in individuals who are overweight and obese.

These findings were supported by an analysis of 15 prospective cohort studies involving over 3,000,000 participants.

Overall, adults with obesity had a 35% lower risk of sustaining hip fractures compared to normal weight individuals.

While obesity may well be a protective factor for hip fractures, unfortunately, obesity remains a significant risk factor for joint problems in both hips and knees.

So this finding may not be quite enough to write home about.

AMS
Banff, Alberta

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Tuesday, October 30, 2012

Obesity Network Joins the Arthritis Alliance of Canada

Regular readers may recall a previous post outlining the importance of obesity as a key driver of osteoarthritis and perhaps even of other inflammatory forms of joint disease.

Yesterday, I had the privilege of attending a membership meeting of the Arthritis Alliance of Canada on behalf of the Canadian Obesity Network – a new member of this alliance.

With now more than 35 member organizations, the Alliance brings together arthritis health care professionals, researchers, funding agencies, governments, voluntary sector agencies, industry and, most importantly, representatives from arthritis consumer organizations from across Canada to provide a central focus for national arthritis-related initiatives.

The Alliance focuses on three distinct strategies:

  • Advance knowledge and awareness of arthritis
  • Identify opportunities and prescribe plans to improve prevention and care
  • Support ongoing collaboration among stakeholders, government, other chronic disease groups

Obviously, all of this is of great interest to many overweight and obese individuals living with arthritis – irrespective of whether or not their weight is the root cause or simply a contributor to their joint pain.

For clinicians, as was pointed out in yesterday’s meeting, at least a cursory knowledge of assessing clients for joint problems should be part of a standard assessment – certainly a must for all patients presenting with excess weight. (Assessment for Osteoarthritis and joint pain are part of the 5As of Obesity Management ‘Assess’).

Reason enough for the Canadian Obesity Network to partner with and strongly support the goals of the Alliance.

AMS
Toronto, ON

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Monday, May 7, 2012

Removing the Cause of Weight Gain Does Not Mean Weight Loss

One of the most common misconceptions about obesity management is that identifying and addressing a potential contributor to weight gain should automatically translate into weight loss – it does not!

As I pointed out in a recent post, when you identify and address the cause of weight gain – weight gain stops, and that’s usually it!

That many of us fail to recognize this rather simple principle, is again illustrated by a paper by Penner and colleagues published in the Journal of Joint and Bone Surgery, which found that successful ankle reconstruction surgery does not decrease BMI in overweight and obese patients.

According to their findings, the 145 patients with excess weight who underwent successful ankle replacement or ankle fusion, despite significant improvements in Ankle Osteoarthritis Scale (AOS) scores and increased physical activity scores, pretty much maintained their preoperative BMI levels at six months and one, two, and five years.

Based on these findings, the authors conclude that:

“Pain and disability are significantly reduced in overweight and obese patients after successful ankle replacement or fusion. Despite this, the mean BMI remains unchanged after the surgery, indicating that weight loss does not commonly occur following successful ankle reconstruction in this patient population. Obesity is likely attributable to factors other than limited mobility caused by ankle arthritis.”

Obviously, the authors assumed that if limited mobility caused weight gain, then increasing mobility should reduce it – that, however, is not what happens.

Rather, what they found, is exactly what I would expect – with regain of their mobility, patients stopped gaining weight – and that’s all.

Without a targeted obesity treatment strategy, there is indeed no reason to expect that these patients would now begin losing weight simply because their activity levels may now be somewhat higher than before. The few extra calories that they may perhaps now burn as a result of being more physically active would easily be compensated by an increased intake or other biological mechanisms that are there to ‘defend’ their current weight.

Thus, the observation that successful ankle surgery did not result in ‘spontaneous’ weight loss neither disproves nor proves that pain or disability may have contributed to weight gain in the first place – it probably did in some and probably did not in others.

Interestingly enough, I believe that this study also bears an important lesson for those attempting to address obesity at a societal level – even if we did know what exactly is driving the obesity epidemic – removing this cause does not necessarily mean everyone gets thinner – it just means that things may hopefully not get worse.

AMS
Berlin, Germany

ResearchBlogging.orgPenner MJ, Pakzad H, Younger A, & Wing KJ (2012). Mean BMI of Overweight and Obese Patients Does Not Decrease After Successful Ankle Reconstruction. The Journal of bone and joint surgery. American volume, 94 (9) PMID: 22552679

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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