Is It Beneficial to Delay Surgery for Weight Loss in Obese Patients Before THA?

Commentary More than 40% of adults in the United States are obese (body mass index [BMI] of ≥30 kg/m2), and >9% are morbidly obese (BMI of ≥40 kg/m2)1. Being overweight is a risk factor for intra- and postoperative complications, such as infection, delayed wound healing, and blood clots, and causes challenges in physical rehabilitation. Although delaying surgery in an attempt for patients with obesity to reduce weight has been recommended for many years, there is a striking lack of evidence supporting this practice. As advancements in surgical techniques and implant materials have evolved, certain traditions in patient selection and operative management remain, and in some cases are based on outdated information or generalized assumptions. In a 2014 article, Husted et al. presented traditions and myths in hip and knee arthroplasty; several such traditions were compared against published evidence and were refuted2. It is remarkable to see that some of those traditions are still in use today. If this leads to a large group of patients not receiving the best possible treatment, such traditions become very problematic. Therefore, Seward et al. should be commended for challenging the widely held opinion that total hip arthroplasty (THA) in patients with severe obesity should be delayed in favor of weight reduction. In their retrospective study of a large group of patients who underwent primary THA, Seward et al. identified patients with a BMI of ≥30kg/m2 and compared those who had maintained, lost, or gained weight prior to surgery. The mean follow-up was 5 years. They evaluated the impact of preoperative weight change on hospital length of stay, operative time, discharge to home or a rehabilitation facility, complications (e.g., deep venous thromboembolism, pulmonary embolism, delayed wound healing or drainage, wound dehiscence, superficial wound infection, and periprosthetic joint infection), revision (exchange of any component of the prothesis), and any other reoperation related to THA. The authors found that 55% of patients maintained or gained weight prior to surgery, 12% lost ≥20 pounds (9 kg), and only 28% of patients with a preoperative BMI of ≥40 kg/m2 were able to reduce their weight to achieve a BMI of <40 kg/m2 before primary THA. The results for the overall cohort were excellent, with a reoperation rate of 5% and a revision rate of 3% after 10 years. The American Society of Anesthesiologists (ASA) classification was 3 in 44.8% of the patients and 4 in 1.3%. Essentially no differences were found in complications, revisions, or reoperations for any preoperative weight loss category when compared with patients who had maintained their weight. The low complication and reoperation rates even in severely obese patients (with almost half having an ASA class of ≥3) were excellent, and demonstrated the expertise and quality of this study that was performed at a high-volume center. However, the results regarding the benefits of preoperative weight loss should be interpreted accordingly, as they might not be reproduced by lower-volume centers. In addition, the authors could not determine if, or which, preoperative weight loss instructions had been given to the patients. With individualized support, such as low-impact exercise programs and nutritional counseling, more patients may be able to reduce their weight. In addition, the role and possible benefit of weight reduction with glucagon-like peptide-1 (GLP-1) agonists in the initial nonoperative treatment of osteoarthritis should be evaluated in future studies. In summary, it is certainly still justified to discuss weight reduction and offer appropriate supportive therapies for severely overweight patients prior to surgery. If, however, the patient is having severe symptoms that cannot be controlled nonoperatively, excess weight should no longer be an argument for delaying THA.