Accepted Manuscript

Title: Obesity and osteoarthritis

Author: Kunal Kulkarni Timothy Karssiens Vijay Kumar

Hemant Pandit

PII: S0378-5122(16)30077-9
DOI: http://dx.doi.org/doi:10.1016/j.maturitas.2016.04.006
Reference: MAT 6593

To appear in: Maturitas

Received date: 4-4-2016

Accepted date: 8-4-2016

Please cite this article as: Kulkarni Kunal, Karssiens Timothy,

Kumar Vijay, Pandit Hemant.Obesity and osteoarthritis.Maturitas
http://dx.doi.org/10.1016/j.maturitas.2016.04.006

This is a PDF file of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its final form. Please note that during the production process
errors may be discovered which could affect the content, and all legal disclaimers that
apply to the journal pertain.
Highlights

 Osteoarthritis is a leading cause of disability. The knee joint is most affected.

 There is an association between obesity and knee osteoarthritis.
 Rising obesity trends result in more total knee arthroplasty (TKA).
 Obese patients can benefit from total knee arthroplasty despite higher risks and
more uncertain outcomes.
 A high boby mass index (BMI) should not be an absolute contraindication to knee
replacement.

Obesity and Osteoarthritis

Mr Kunal Kulkarni1, Mr Timothy Karssiens1, Prof Vijay Kumar2, Prof Hemant Pandit3
1
East and North Hertfordshire NHS Trust, Lister Hospital, Stevenage, SG1 4AB, UK
2
All India Institute of Medical Sciences, New Delhi, 110029, India
3
Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Centre, Oxford, OX3 7LD, UK

Corresponding author: kunalkulkarni@doctors.org.uk

Abstract
This paper provides an up-to-date review of obesity and lower limb osteoarthritis (OA). OA is a
major global cause of disability, with the knee being the most frequently affected joint. There is a
proven association between obesity and knee OA, and obesity is suggested to be the main
modifiable risk factor. Obese patients (Body Mass Index, BMI, over 30kg/m2) are more likely to
require total knee arthroplasty (TKA). The global prevalence of obesity has doubled since 1980;
by 2025, 47% of UK men and 36% of women are forecast to be obese. This rising global burden
is a key factor in the growing rise in the use of TKA. It is therefore important to appreciate the
outcomes of surgery in patients with end-stage OA and a high BMI.

This review found that while OA is felt to contribute to weight gain, it is unclear whether TKA
facilitates weight reduction. Surgery in obese patients is more technically challenging. This is
reflected in the evidence, which suggests higher rates of short- to medium-term complications
following TKA, including wound infection and medical complications, resulting in longer hospital
stay, and potentially higher rates of malalignment, dislocation, and early revision. However,
despite slower initial recovery and possibly lower functional scores and implant survival in the
longer term, obese patients can still benefit from TKA in terms of improved function, quality of life
and satisfaction.

In conclusion, despite higher risks and more uncertain outcomes of surgery, higher BMI in itself
should not be a contraindication to TKA; instead, each patient‟s individual circumstances should
be considered.

Keywords
Obesity, osteoarthritis, arthroplasty, knee, replacement, outcomes

Introduction
This paper provides an up-to-date review on obesity and lower limb osteoarthritis (OA). It
provides an evidence-based opinion regarding the burden of obesity, its contribution to the aetio-
pathogenesis of osteoarthritis, with specific reference to knee OA, and the impact of obesity on
the outcome of treatments offered to treat end-stage osteoarthritis.

Osteoarthritis
Osteoarthritis (OA) is the clinical syndrome of joint pain accompanied by varying degrees of
functional limitation and reduced quality of life. Pathologically, it is characterised by localised loss
of cartilage, remodelling of adjacent bone, and associated inflammation.[1]

Globally, hip and knee OA are the 11th highest contributors to global disability, with ageing
populations expected to result in a jump to 4th by 2020. [1-3] This significant disease burden
results in 88,763 hip replacements and 96,986 knee replacements performed in the UK each
year. [4]

The knee is the most frequently affected joint. Knee OA affects 8.5 million people in the UK. [5]
Females are affected more commonly than males (global prevalence 4.8% versus 2.8% for men).
[6] As women live longer, the majority of patients undergoing any total joint arthroplasty (TJA) are
women, comprising 55% to 70% of most studies. [7-13] Opinion remains divided on whether total
knee arthroplasty (TKA) should be performed in patients with higher BMI, given suggested poorer
outcomes and higher risk of complications. The higher additional costs of undertaking TKA in
obese patients (approximately £2,135 per patient) places a higher burden on healthcare services,
so the benefits in terms of functional and symptomatic improvement should be significant enough
to warrant the additional risks. [14]

Obesity
The global prevalence of obesity has doubled since 1980. [15, 16] Between 1993 and 2012 in the
UK, the proportion of overweight and obese adults increased from 57.6% to 66.6% (men) and
48.6% to 57.2% (women). The precise factors causing obesity remain under debate. The
Foresight Report concluded a “complex web of societal and biological factors that have, in recent
decades, exposed our inherent human vulnerability to weight gain”. [17]

The World Health Organisation (WHO) has defined several classifications of weight, based on
Body Mass Index (BMI), including „overweight‟ (BMI > 25kg/m2) and „obese‟ (BMI > 30kg/m2).[15,
16] Obesity is further sub-classified as class I (BMI 30-34.99kg/m2), Class II (35-39.99kg/m2) and
class III („morbidly obese‟ ≥40kg/m2). A more recent category is „super obese‟ (BMI >50kg/m2).

By 2025, it predicted 47% of UK men and 36% of women (aged between 21 and 60 years) would
be obese. By 2050 the predictions are worse, with 60% adult men, 50% adult women, and 25%
children (under 16 years) forecasted to be obese. Alongside the additional health risks to the
individual – including chronic diseases such as heart disease, diabetes, hypertension, and
elevated cholesterol – obesity is associated with higher healthcare costs; obese patients are
estimated to incur 46% higher inpatient and 27% more outpatient costs. [18, 19]

Link between obesity and knee OA

Cross-sectional and longitudinal studies have consistently demonstrated an association between
obesity, usually assessed by BMI, and the prevalence and incidence of knee OA, with obesity
proposed to be the main modifiable risk factor. [20-24]

Several large cohort studies have corroborated these findings using radiographic assessment of
OA, including diagnostic changes of OA and bone volume.[23, 25] Pattern of weight gain may be
relevant, with a shift from normal to overweight in adult life carrying a higher risk for knee OA
requiring TKA than being constantly overweight. [26]
While radiographic markers of OA usually correlate with patient symptoms, this is not always the
case, with studies showing radiographic OA changes to not always be associated with knee pain.
[27] Aiming to show a similar association between obesity and OA using patient symptoms, rather
than radiographic changes alone, some studies have found BMI to be a predictor of knee pain,
independent of radiographic features. [28, 29]

Pathogenesis of obesity and OA

A variable combination of mechanical, humeral, metabolic and genetic factors are thought to play
a role in the pathogenesis of OA. [30-32] With obesity, excess weight increases joint loading,
resulting in deleterious effects on weight-bearing joints. The additional mass can stress articular
cartilage beyond biological capabilities, therefore causing degenerative changes.[23, 24] Gait
analysis has demonstrated weight loss to reduce load across the knee joint, with approximately
0.5 kg weight loss resulting in a two- to four-fold reduction per step. [33, 34]

OA develops when cartilage breaks down faster than it is produced. Fat mass, rather than
skeletal muscle mass, is a risk factor for cartilage defects; for every 1 kg increase in total body fat
there is an increased risk of cartilage defects – a feature of early knee OA. [35] Metabolic and
humeral factors may account for why a higher incidence of OA in individuals with higher BMI and
body fat is found in non-weight bearing joints such as the hands. [36-38] Similarly, metabolic
syndrome increases the risk of knee OA but not hip OA, suggesting mechanical factors may not
be solely responsible. [39]

Does weight loss improve OA?

Despite strong evidence linking weight gain to the development of knee OA, there is a relative
paucity of evidence examining the impact of weight reduction, and the subsequent reduction in
load across the joint, on improvements in either the symptoms or radiographic features of
established OA. [23] [40] [41]

Some studies have shown a reduction in BMI to reduce the risk of development of radiographic
knee OA, with a large population study finding a reduction in BMI of ≥2 kg/m2 over 10 years
decreased the odds for developing knee OA by over 50%. [42, 43] Using symptoms as a marker,
significant bariatric surgery-induced weight loss can improve both hip and knee pain associated
with OA. [40] Non-operative weight loss of at least 5.1%, including through dietary intervention,
also yields symptomatic improvement. [41] Whether weight change modifies both knee joint
cartilage volume and symptoms in the same cohort has not been widely assessed, but surgically-
induced weight loss appears to an effective, rapid and dependable means of increasing medial
joint space while also improving symptom scores.[44] While most studies found significant weight
loss to be required to derive symptomatic and structural improvements, smaller degrees of
weight loss may still benefit people at high risk of knee OA, thereby modifying their trajectory
toward clinically significant knee OA. [41, 45]

Does obesity increase the need for arthroplasty?

The evidence strongly suggests an increased risk of obese patients requiring TKA. [46] [47, 48]
Some studies report over 90% patients undergoing TKA are overweight or obese, with the UK‟s
NJR reporting the average BMI of patients undergoing TKR to be 30.85 (i.e. obese). [49] [50] [4]

Higher BMI appears to confer a higher risk of needing total knee arthroplasty (TKA). [8] One
study reported an odds ratio (OR) for requiring TKA of 1.7 for overweight and 5.3 for obese men,
and 1.6 for overweight and 4 for obese women. [51] A similar study found more significant
results, with the highest odds ratio in male patients with BMI 37.5 to 39.9kg/m2 (OR 16.40) and
females with BMI ≥40 kg/m2 (OR 19.05). [46]

Change from an individual‟s baseline BMI may confer greater risk, with an increase in 1 kg/m2 of
BMI from baseline shown to yield a significant 10.5% increased lifetime risk of TKA, and a
5kg/m2 BMI increase to nearly double the risk of TKA, with obese patients requiring TKA from
seven to thirteen years earlier than non-obese counterparts. [47] [52] [53] [100]
Have rising obesity trends increased the uptake of arthroplasty?
91% THA and 98% TKA are performed for OA. [4] The average BMI of patients undergoing TKA
in 2014 was 30.85kg/m2 – a significant rise from an average of 27.5 kg/m2 a decade earlier. By
2030, the global incidence of TKA is forecast to increase by 673%, compared with 2005 levels.
[54] Furthermore, the time between first TJA and TJA of the contralateral joint is also expected to
decrease due to a higher risk of bilateral osteoarthritis at a younger age in obese patients. [55]

Do patients lose weight after TKA?

OA is often felt to be a contributing factor in weight gain due to joint pain limiting an individual‟s
activity, thereby reducing caloric expenditure. TKA has been assumed to tame the weight gain
curve by facilitating activity, with patients not undergoing TKA expected to increasingly limit their
activity as symptoms progress, exhibiting steeper increases in BMI over time. However, the
results of several studies examining post-TJA weight change are inconsistent.[56]

Several large studies and systematic reviews have found no conclusive evidence of weight or
BMI being altered by TKA, at up to five years‟ follow up. [57] [58] Despite this, patients report
significant improvement in functional scores. [57] [59] [60] [61]

A limited number of studies have found patients demonstrate a significant reduction in BMI
following TKA, with one review finding weight loss in 14 to 49% of patients. [57] [56, 58] [62]
Morbidly obese patients in particular were shown to be more likely to lose a clinically significant
amount of weight before and/or after TJA. [61]

Some believe the balance of evidence has shifted increasingly towards concluding that patients
actually gain weight post-TKA. [9, 13, 56, 63-66] [67] However, these patients still demonstrated
a significant improvement in Oxford outcome scores and mobility. [65] [67] Younger patients
have been shown to be more likely to gain weight post-TKA, with their older counterparts more
likely to show weight loss. [61] [13]

TKA cannot therefore be considered as a means in itself to produce weight loss in overweight
and obese patients. Similarly variable results have been found following THA. [3] One important
caveat is the separation of post-operative weight change from function; irrespective of changes in
weight, obese patients with OA are generally still satisfied with the outcomes of surgery –
regardless of whether gains in functional ability can later translate into new physical activity
habits to support weight management. [9, 63, 68]

Are complication rates higher in obese patients undergoing TJA?

Short-medium term
There is an abundance of evidence to suggest higher rates of short-to-medium term
complications following TKA in obese patients, with even higher rates in super obese patients,
resulting in significantly longer hospital stay, with the magnitude of risk increasing with BMI, and
potentially higher rates of malalignment, dislocation, and early revision. [69] [70, 71] [72] [73] [74]

30% of obese patients undergoing TKA have at least 3 comorbidities (e.g. diabetes, coronary
artery disease, hyperlipidemia, hypertension, sleep apnoea), compared with only 7% of non-
obese patients, which increases the risk of peri-operative complications. [13] [59, 75] [76] These
adversely affect anaesthesia, with around 30% of super obese patients requiring intensive care
unit monitoring post-operatively, and 9% requiring respiratory assistance.[77] Increased BMI is
known to independently increase the likelihood of pulmonary embolism (PE) or deep venous
thrombosis (DVT). [78] [79] Higher mortality rates are also reported, with a large meta-analysis
finding 5 kg/m2 higher BMI was associated with 30% higher overall mortality. [80]

Operating on obese patients is technically challenging, and complications can arise due to
difficulties in positioning and failure to gain adequate surgical exposure.[81] Consequently,
obesity is associated with a higher incidence of technical errors during TKA, likely contributing to
poorer range of motion. [82] Poor access may also be a factor resulting in significantly higher
volumes of blood loss reported during TJA in obese patients. [83] Particularly in morbidly obese
patients, obtaining adequate exposure generally results in increased operative time, which can
expose patients to a higher risk of infection and other medical complications. [84, 85]

Significantly higher rates of superficial (wound) and deep (peri-prosthetic) infection have
consistently been reported in obese patients. [86] [87] [72] Morbid obesity, diabetes, and younger
age are independent risk factors that confer even higher rates of deep infection, with reported OR
of between 3.2 to 9 compared to controls [59] [88] [132] Super obese patients have even greater
OR of 21.3.[88]

Despite the significant evidence-base suggesting higher complication rates, it is important to note
that several large studies have reported similar anaesthetic times, length of stay, wound infection
rates, and complication rates at up to 10 years post-operatively, resulting in comparable implant
survivorship to non-obese patients. [89] [7, 90, 91] [92] [93] [94]

Long-term
The prevailing opinion has been that obese patients experience poorer functional outcomes after
TKA compared with non-obese counterparts, due to a combination of higher earlier complications
and an assumption of increased loads across the joint contributing to earlier wear. [95, 96] Earlier
studies had found significantly poorer functional scores (including pain, stiffness, range of motion
and physical function) and inferior survivorship (using revision and pain as end-points) at up to 4
years post-operatively in obese and morbidly obese patients. [87] [95] Approach has generally
been to advise patients to lose weight prior to consideration for TKA.

However, a number of these studies were limited by small sample sizes, low event rates, failure
to consider comorbidities, short follow up periods, and failure to stratify patients by BMI. [97] As
obese patients tend to have lower preoperative functional scores, higher postoperative scores in
the non-obese may reflect a pre-operative difference. [70] Furthermore, very few studies
distinguish function scores from practical patient satisfaction (i.e. whether patients felt they had
benefitted from surgery). One of the few studies to evaluate patient satisfaction reported similar
3-year pain and function outcome scores between obese and non-obese patients; however,
almost a third of patients with BMI >35 kg/m2 reported being dissatisfied following TKA and
would not have the procedure again. [98]

A significant body of evidence has since amassed that challenges the belief that obese patients
have poorer longer-term outcomes following TKA and suggests they benefit from TKA as much
as their non-obese counterparts despite more technically challenging surgery, more post-
operative complications, slower initial recovery, and possibly lower functional scores. [69] [72, 88]
[94] [99] While non-obese patients may show greater initial improvement in function and pain
scores, some studies have found no significant difference in the longer-term. [47] [91] [92] [100]
[101]

Similar findings have been reported following unicompartmental knee arthroplasty (UKA), a less
invasive option for OA affecting a single compartment of the knee, with one study reporting no
significant difference between obese and non-obese patients in implant survival or Objective
American Knee Society Score at mean follow up of 5 years. [102] While there was a significant
trend with other functional outcomes (Oxford Knee and Functional American Knee Society
Scores) decreasing with increasing BMI, the opposite trend (p<0.01) was observed in pre-
operative Oxford Knee Score, with its change increasing with BMI (p=0.048). The mean age at
surgery was significantly (p<0.01) lower in patients with higher BMI. The authors concluded that
increasing BMI was neither associated with increasing failure rates nor was it associated with
decreasing benefit from UKA.

While lower BMI is a predictor of better post-operative physical function, over 80% of patients are
nonetheless satisfied with the results of TKA at up to 14 years follow up, irrespective of BMI,
reporting significant and persistent relief of pain, improved physical function, and overall
satisfaction. [103] [104] Data from the UK‟s National Joint Registry (NJR) shows worse pre-
operative Oxford Knee Scores (OKS) in obese patients, with more variable post-TKR scores,
median scores in obese patients were 3 to 4 points lower than for other BMIs. [4]

Several large studies have reported significantly poorer implant survival in obese patients, with a
systematic review concluding 10-year implant survival rates of 92.74% in obese patients,
compared with 98.45% in the non-obese. [105] [86] [106] As a result, the need for revision
increases. However, the evidence-base is not consistent, with a substantial body concluding no
significant difference in overall implant survival post-TKA in obese patients, compared to their
non-obese counterparts, as evaluated by radiographic analysis and revision rates. [93] [94] [101]
[107] [108] [109]

With unclear longer-term results on implant survivorship, the advantages of improved function,
quality of life and patient satisfaction may therefore outweigh the increased shorter-term risks of
TKA in obese patients. [110]

Discussion
The global prevalence of obesity is rising. With a forecasted 11 million more obese individuals in
the UK by 2030, costs of treating preventable obesity-related diseases are set to increase to £2
billion/year. [111] Coupled with an ageing, older population, the burden of OA is also set to rise,
resulting in the demand for TKA expected to rise up to 600% over the next 15 to 20 years. [112]
[113] With a growing proportion of obese patients requiring TKA, it is important that patients,
clinicians and healthcare providers are prepared for the additional technical, medical and
financial peri-operative challenges. [114]

There is growing evidence to suggest longer-term outcomes of TKA in obese patients are
comparable to those of their non-obese counterparts. However, this may be at the expense of
more short-to-medium term complications. TKA in morbidly obese patients requires 7% higher
hospital resource utilisation. [115] An infected TKR requires up to 4 times the resources of a
primary TKA – an important consideration given the reportedly higher rates of deep infections
following TKA in obese patients. [116] However, these additional costs need to be balanced
against the „hidden‟ costs of reduced quality of life and impaired function in those with
symptomatic OA.

TJA in overweight and obese patients remains a contentious subject. In the UK, the National
Institute for Health and Clinical Excellence (NICE) advise “referral for joint replacement surgery
should be considered for people with OA who experience joint symptoms (pain, stiffness,
reduced function) that have a substantial impact on their quality of life and are refractory to non-
surgical treatment. Referral should be made before there is prolonged and established functional
limitation and severe pain.” [1] In practice – for financial grounds or otherwise - most Clinical
Commissioning Groups (CCGs) usually require reasonable attempts for weight management to
have been made in patients above certain BMI thresholds (particularly morbidly obese, i.e.
≥40kg/m2) prior to eligibility for TJA, including through referral to specialist services. [117, 118]
For those unable to achieve weight loss, exceptional case-by-case exceptions may occasionally
be considered, including severe pain, mobility compromise, an immediate risk of loss of
independence, or where further delay would increase the technical difficulty of the procedure.
[119]

Expecting obese patients with OA to lose weight prior to TKA may be unsuccessful as their
symptoms may limit the ability to exercise. There also remains the belief that TJA is crucial for
weight loss. [13] Irrespective of guidelines and referral criteria, preoperative weight loss should
nonetheless be encouraged to improve surgical outcomes and the patient‟s general health and
wellbeing. [63] Options include lifestyle measures, non-operative treatments (behaviour
medication and pharmacological treatment), and surgically assisted weight loss. [120] Bariatric
surgery for specific patients - such as the morbidly obese and in whom lifestyle and medical
treatments have failed – can be successful (expected excess weight loss of ≥50%), resulting in
improved medical comorbidities, health-related quality of life, and likely significantly improved
functional outcomes from TKA. [7, 30, 121]
High preoperative BMI should therefore not necessarily preclude TKA, with evidence suggesting
TKA can yield positive outcomes in patients with higher BMI, including improvements in quality of
life, mobility, and pain. However, to manage expectations, both surgeons and patients should be
aware that functional and symptomatic improvement may not be as great as in non-obese
patients, and may be compromised by a higher incidence of perioperative and short-term
complications, particularly in the morbid and super obese, with a higher risk of need for revision.
[13, 49, 63] Each patient being considered for TKA is unique and the decision to proceed with
surgery should only be made after full counselling regarding the likely risks and benefits in the
context of a patient‟s individual circumstances. Preoperative weight loss - particularly in morbidly
and super obese patients - may improve outcomes, and post-TKA activity and behavioral
intervention programmes may also be advisable to maximise benefit from TKA, with studies
demonstrating that patients value the additional support in encouraging an increase in physical
activity and exercise following TKA. [122]

Conclusion
While OA is can contribute to weight gain, it is unclear whether TKA facilitates weight reduction.
Surgery in obese patients is more technically challenging. This is reflected in the evidence, which
suggests higher rates of short-to-medium term peri-operative complications following TKA,
including wound infection and medical complications, resulting in longer hospital stay, and
potentially higher rates of malalignment, dislocation, and early revision. However, despite slower
initial recovery and possibly lower functional scores and implant survival in the longer-term,
obese patients can also benefit from TKA (in terms of relatively improved function, quality of life
and patient satisfaction). In conclusion, despite higher risks and more uncertain outcomes of
surgery, higher BMI in itself should not be a contraindication to TKA, with each patient‟s
individual circumstances considered

Contributors
KK and TK wrote the initial draft and completed the final edits. VK and HP reviewed and edited
the initial draft as senior authors.
All authors declare that they have participated in the preparation of the paper and that they have
seen and approved the final version.

Conflict of interest
None declared.

Funding
No funding has been received for this article.

Provenance and peer review

This article has undergone peer review.

References
[1] (NICE) NIfHaCE. Osteoarthritis: Care and management in adults. Clinical guideline CG177. Methods,
evidence and recommendations. February 2014. 2014.
[2] Murray CJ, Lopez AD. Evidence-based health policy--lessons from the Global Burden of Disease Study.
Science. 1996;274:740-3.
[3] Woolf VJ, Charnley GJ, Goddard NJ. Weight changes after total hip arthroplasty. The Journal of
arthroplasty. 1994;9:389-91.
[4] National Joint Registry for England WaNI. 12th Annual Report. 2015. 10th ed2015.
[5] Care A. OA Nation: The most comprehensive UK report of people with osteoarthritis. April 2014. 2014.
[6] Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, et al. The global burden of hip and knee
osteoarthritis: estimates from the Global Burden of Disease 2010 study. Annals of the rheumatic diseases.
2014.
[7] Inacio MC, Kritz-Silverstein D, Raman R, Macera CA, Nichols JF, Shaffer RA, et al. The impact of pre-
operative weight loss on incidence of surgical site infection and readmission rates after total joint
arthroplasty. The Journal of arthroplasty. 2014;29:458-64 e1.
[8] Apold H, Meyer HE, Nordsletten L, Furnes O, Baste V, Flugsrud GB. Weight gain and the risk of knee
replacement due to primary osteoarthritis: A population based, prospective cohort study of 225,908
individuals. Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society. 2014.
[9] Riddle DL, Singh JA, Harmsen WS, Schleck CD, Lewallen DG. Clinically important body weight gain
following knee arthroplasty: a five-year comparative cohort study. Arthritis care & research. 2013;65:669-
77.
[10] Pugely AJ, Callaghan JJ, Martin CT, Cram P, Gao Y. Incidence of and risk factors for 30-day
readmission following elective primary total joint arthroplasty: analysis from the ACS-NSQIP. The Journal
of arthroplasty. 2013;28:1499-504.
[11] Liljensoe A, Lauersen JO, Soballe K, Mechlenburg I. Overweight preoperatively impairs clinical
outcome after knee arthroplasty: a cohort study of 197 patients 3-5 years after surgery. Acta
orthopaedica. 2013;84:392-7.
[12] Maradit Kremers H, Visscher SL, Kremers WK, Naessens JM, Lewallen DG. Obesity increases length of
stay and direct medical costs in total hip arthroplasty. Clinical orthopaedics and related research.
2014;472:1232-9.
[13] Dowsey MM, Liew D, Stoney JD, Choong PF. The impact of pre-operative obesity on weight change
and outcome in total knee replacement: a prospective study of 529 consecutive patients. J Bone Joint
Surg Br. 2010;92:513-20.
[14] Rodriguez-Merchan EC. The Influence of Obesity on the Outcome of TKR: Can the Impact of Obesity
be justified from the Viewpoint of the Overall Health Care System? HSS journal : the musculoskeletal
journal of Hospital for Special Surgery. 2014;10:167-70.
[15] Organisation WH. Obesity and overweight: Fact sheet No. 311. 2013.
[16] Organisation WH. Global Database on Body Mass Index. 2014.
[17] Science UGOf. FORESIGHT. Tackling Obesities: Future Choices – Project Report. 2nd edition. . 2nd
ed2007.
[18] Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity:
payer-and service-specific estimates. Health Aff (Millwood). 2009;28:w822-31.
[19] Costa-Font J, Gil J. Obesity and the incidence of chronic diseases in Spain: a seemingly unrelated
probit approach. Econ Hum Biol. 2005;3:188-214.
[20] Anderson JJ, Felson DT. Factors associated with osteoarthritis of the knee in the first national Health
and Nutrition Examination Survey (HANES I). Evidence for an association with overweight, race, and
physical demands of work. Am J Epidemiol. 1988;128:179-89.
[21] Felson DT, Anderson JJ, Naimark A, Walker AM, Meenan RF. Obesity and knee osteoarthritis. The
Framingham Study. Ann Intern Med. 1988;109:18-24.
[22] Cooper C, Snow S, McAlindon TE, Kellingray S, Stuart B, Coggon D, ;, et al. Risk factors for the
incidence and progression of radiographic knee osteoarthritis. Arthritis and rheumatism. 2000;43:995-
1000.
[23] Teichtahl AJ, Wang Y, Wluka AE, Cicuttini FM. Obesity and knee osteoarthritis: new insights provided
by body composition studies. Obesity. 2008;16:232-40.
[24] Teichtahl AJ, Wluka AE, Tanamas SK, Wang Y, Strauss BJ, Proietto J, et al. Weight change and change
in tibial cartilage volume and symptoms in obese adults. Annals of the rheumatic diseases. 2014.
[25] Gunardi AJ, Brennan SL, Wang Y, Cicuttini FM, Pasco JA, Kotowicz MA, et al. Associations between
measures of adiposity over 10 years and patella cartilage in population-based asymptomatic women.
International journal of obesity. 2013;37:1586-9.
[26] Manninen P, Riihimaki H, Heliovaara M, Suomalainen O. Weight changes and the risk of knee
osteoarthritis requiring arthroplasty. Annals of the rheumatic diseases. 2004;63:1434-7.
[27] Cicuttini FM, Baker JR, Spector TD. The association of obesity with osteoarthritis of the hand and
knee in women: a twin study. J Rheumatol. 1996;23:1221-6.
[28] Oliveria SA, Felson DT, Cirillo PA, Reed JI, Walker AM. Body weight, body mass index, and incident
symptomatic osteoarthritis of the hand, hip, and knee. Epidemiology. 1999;10:161-6.
[29] Goulston LM, Kiran A, Javaid MK, Soni A, White KM, Hart DJ, et al. Does obesity predict knee pain
over fourteen years in women, independently of radiographic changes? Arthritis care & research.
2011;63:1398-406.
[30] Sridhar MS, Jarrett CD, Xerogeanes JW, Labib SA. Obesity and symptomatic osteoarthritis of the
knee. J Bone Joint Surg Br. 2012;94:433-40.
[31] Eaton CB. Obesity as a risk factor for osteoarthritis: mechanical versus metabolic. Med Health R I.
2004;87:201-4.
[32] Iannone F, Lapadula G. Obesity and inflammation--targets for OA therapy. Curr Drug Targets.
2010;11:586-98.
[33] Messier SP, Gutekunst DJ, Davis C, DeVita P. Weight loss reduces knee-joint loads in overweight and
obese older adults with knee osteoarthritis. Arthritis and rheumatism. 2005;52:2026-32.
[34] Aaboe J, Bliddal H, Messier SP, Alkjaer T, Henriksen M. Effects of an intensive weight loss program on
knee joint loading in obese adults with knee osteoarthritis. Osteoarthritis and cartilage / OARS,
Osteoarthritis Research Society. 2011;19:822-8.
[35] Berry PA, Wluka AE, Davies-Tuck ML, Wang Y, Strauss BJ, Dixon JB, et al. The relationship between
body composition and structural changes at the knee. Rheumatology. 2010;49:2362-9.
[36] Scrivo R, Vasile M, Muller-Ladner U, Neumann E, Valesini G. Rheumatic diseases and obesity:
adipocytokines as potential comorbidity biomarkers for cardiovascular diseases. Mediators of
inflammation. 2013;2013:808125.
[37] Yusuf E, Nelissen RG, Ioan-Facsinay A, Stojanovic-Susulic V, DeGroot J, van Osch G, et al. Association
between weight or body mass index and hand osteoarthritis: a systematic review. Annals of the
rheumatic diseases. 2010;69:761-5.
[38] Visser AW, Ioan-Facsinay A, de Mutsert R, Widya RL, Loef M, de Roos A, et al. Adiposity and hand
osteoarthritis: the Netherlands Epidemiology of Obesity study. Arthritis Res Ther. 2014;16:R19.
[39] Engstrom G, Gerhardsson de Verdier M, Rollof J, Nilsson PM, Lohmander LS. C-reactive protein,
metabolic syndrome and incidence of severe hip and knee osteoarthritis. A population-based cohort
study. Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society. 2009;17:168-73.
[40] Gill RS, Al-Adra DP, Shi X, Sharma AM, Birch DW, Karmali S. The benefits of bariatric surgery in obese
patients with hip and knee osteoarthritis: a systematic review. Obes Rev. 2011;12:1083-9.
[41] Christensen R, Bartels EM, Astrup A, Bliddal H. Effect of weight reduction in obese patients diagnosed
with knee osteoarthritis: a systematic review and meta-analysis. Annals of the rheumatic diseases.
2007;66:433-9.
[42] Felson DT, Zhang Y, Hannan MT, Naimark A, Weissman B, Aliabadi P, et al. Risk factors for incident
radiographic knee osteoarthritis in the elderly: the Framingham Study. Arthritis and rheumatism.
1997;40:728-33.
[43] Felson DT, Zhang Y, Anthony JM, Naimark A, Anderson JJ. Weight loss reduces the risk for
symptomatic knee osteoarthritis in women. The Framingham Study. Ann Intern Med. 1992;116:535-9.
[44] Abu-Abeid S, Wishnitzer N, Szold A, Liebergall M, Manor O. The influence of surgically-induced
weight loss on the knee joint. Obes Surg. 2005;15:1437-42.
[45] Anandacoomarasamy A, Leibman S, Smith G, Caterson I, Giuffre B, Fransen M, et al. Weight loss in
obese people has structure-modifying effects on medial but not on lateral knee articular cartilage. Annals
of the rheumatic diseases. 2012;71:26-32.
[46] Wendelboe AM, Hegmann KT, Biggs JJ, Cox CM, Portmann AJ, Gildea JH, et al. Relationships between
body mass indices and surgical replacements of knee and hip joints. Am J Prev Med. 2003;25:290-5.
[47] Bourne R, Mukhi S, Zhu N, Keresteci M, Marin M. Role of obesity on the risk for total hip or knee
arthroplasty. Clinical orthopaedics and related research. 2007;465:185-8.
[48] Jackson MP, Sexton SA, Yeung E, Walter WL, Walter WK, Zicat BA. The effect of obesity on the mid-
term survival and clinical outcome of cementless total hip replacement. J Bone Joint Surg Br.
2009;91:1296-300.
[49] Workgroup of the American Association of H, Knee Surgeons Evidence Based C. Obesity and total
joint arthroplasty: a literature based review. The Journal of arthroplasty. 2013;28:714-21.
[50] Suleiman LI, Ortega G, Ong'uti SK, Gonzalez DO, Tran DD, Onyike A, et al. Does BMI affect
perioperative complications following total knee and hip arthroplasty? J Surg Res. 2012;174:7-11.
[51] Franklin J, Ingvarsson T, Englund M, Lohmander LS. Sex differences in the association between body
mass index and total hip or knee joint replacement resulting from osteoarthritis. Annals of the rheumatic
diseases. 2009;68:536-40.
[52] Nicholls AS, Kiran A, Javaid MK, Hart DJ, Spector TD, Carr AJ, et al. 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. The Knee. 2012;19:316-9.
[53] Gandhi R, Wasserstein D, Razak F, Davey JR, Mahomed NN. BMI independently predicts younger age
at hip and knee replacement. Obesity. 2010;18:2362-6.
[54] Kurtz SM, Ong KL, Lau E, Widmer M, Maravic M, Gomez-Barrena E, et al. International survey of
primary and revision total knee replacement. Int Orthop. 2011;35:1783-9.
[55] Stürmer T, Günther KP, Brenner H. Obesity, overweight and patterns of osteoarthritis: the Ulm
Osteoarthritis Study. J Clin Epidemiol. 2000;53:307-13.
[56] Inacio MC, Kritz-Silverstein D, Paxton EW, Fithian DC. Do patients lose weight after joint arthroplasty
surgery? A systematic review. Clinical orthopaedics and related research. 2013;471:291-8.
[57] Woodruff MJ, Stone MH. Comparison of weight changes after total hip or knee arthroplasty. The
Journal of arthroplasty. 2001;16:22-4.
[58] Lachiewicz AM, Lachiewicz PF. Weight and activity change in overweight and obese patients after
primary total knee arthroplasty. The Journal of arthroplasty. 2008;23:33-40.
[59] Samson AJ, Mercer GE, Campbell DG. Total knee replacement in the morbidly obese: a literature
review. ANZ journal of surgery. 2010;80:595-9.
[60] Chang MJ, Kang YG, Chang CB, Seong SC, Kim TK. The patterns of limb length, height, weight and
body mass index changes after total knee arthroplasty. The Journal of arthroplasty. 2013;28:1856-61.
[61] Inacio MC, Silverstein DK, Raman R, Macera CA, Nichols JF, Shaffer RA, et al. Weight patterns before
and after total joint arthroplasty and characteristics associated with weight change. The Permanente
journal. 2014;18:25-31.
[62] Stets K, Koehler SM, Bronson W, Chen M, Yang K, Bronson M. Weight and body mass index change
after total joint arthroplasty. Orthopedics. 2010;33:386.
[63] Vasarhelyi EM, MacDonald SJ. The influence of obesity on total joint arthroplasty. J Bone Joint Surg
Br. 2012;94:100-2.
[64] Zeni JA, Jr., Snyder-Mackler L. Most patients gain weight in the 2 years after total knee arthroplasty:
comparison to a healthy control group. Osteoarthritis and cartilage / OARS, Osteoarthritis Research
Society. 2010;18:510-4.
[65] Abu-Rajab RB, Findlay H, Young D, Jones B, Ingram R. Weight changes following lower limb
arthroplasty: a prospective observational study. Scott Med J. 2009;54:26-8.
[66] Heisel C, Silva M, dela Rosa MA, Schmalzried TP. Heisel C, Silva M, dela Rosa MA, et al. The effects of
lower-extremity total joint replacement for arthritis on obesity. Orthopedics 2005;28:157–159].
Orthopedics. 2005;28:157-9.
[67] Donovan J, Dingwall I, McChesney S. Weight change 1 year following total knee or hip arthroplasty.
ANZ journal of surgery. 2006;76:222-5.
[68] Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with
overweight and obesity. JAMA. 1999;282:1523-9.
[69] Rajgopal V, Bourne RB, Chesworth BM, MacDonald SJ, McCalden RW, Rorabeck CH. The impact of
morbid obesity on patient outcomes after total knee arthroplasty. The Journal of arthroplasty.
2008;23:795-800.
[70] Davis W, Porteous M. Joint replacement in the overweight patient: a logical approach or new form of
rationing? Annals of the Royal College of Surgeons of England. 2007;89:203-6; discussion
[71] Mnatzaganian G, Ryan P, Norman PE, Davidson DC, Hiller JE. Use of routine hospital morbidity data
together with weight and height of patients to predict in-hospital complications following total joint
replacement. BMC Health Serv Res. 2012;12:380.
[72] Winiarsky R, Barth P, Lotke P. Total knee arthroplasty in morbidly obese patients. The Journal of bone
and joint surgery American volume. 1998;80:1770-4.
[73] Friedman RJ, Hess S, Berkowitz SD, Homering M. Complication rates after hip or knee arthroplasty in
morbidly obese patients. Clinical orthopaedics and related research. 2013;471:3358-66.
[74] Schwarzkopf R, Thompson SL, Adwar SJ, Liublinska V, Slover JD. Postoperative complication rates in
the "super-obese" hip and knee arthroplasty population. The Journal of arthroplasty. 2012;27:397-401.
[75] Namba RS, Paxton L, Fithian DC, Stone ML. Obesity and perioperative morbidity in total hip and total
knee arthroplasty patients. The Journal of arthroplasty. 2005;20:46-50.
[76] Odum SM, Springer BD, Dennos AC, Fehring TK. National obesity trends in total knee arthroplasty.
The Journal of arthroplasty. 2013;28:148-51.
[77] Domi R, Laho H. Anesthetic challenges in the obese patient. J Anesth. 2012;26:758-65.
[78] 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;99:552-60; discussion 5A.
[79] Memtsoudis SG, Besculides MC, Gaber L, Liu S, Gonzalez Della Valle A. Risk factors for pulmonary
embolism after hip and knee arthroplasty: a population-based study. Int Orthop. 2009;33:1739-45.
[80] Prospective Studies C. Body-mass index and cause-specific mortality in 900 000 adults: collaborative
analyses of 57 prospective studies. The Lancet. 2009;373:1083-96.
[81] Guss D, Bhattacharyya T. Perioperative management of the obese orthopaedic patient. J Am Acad
Orthop Surg. 2006;14:425-32.
[82] Järvenpää J, Kettunen J, Kröger H, Miettinen H. Obesity may impair the early outcome of total knee
arthroplasty. Scand J Surg. 2010;99:45-9.
[83] Bowditch MG, Villar RN. Do obese patients bleed more? A prospective study of blood loss at total hip
replacement. Annals of the Royal College of Surgeons of England. 1999;81:198-200.
[84] Perka C, Labs K, Muschik M, Buttgereit F. The influence of obesity on perioperative morbidity and
mortality in revision total hip arthroplasty. Arch Orthop Trauma Surg. 2000;150:267-71.
[85] Liabaud B, Patrick DA, Jr., Geller JA. Higher body mass index leads to longer operative time in total
knee arthroplasty. The Journal of arthroplasty. 2013;28:563-5.
[86] 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. The Journal of bone and joint surgery American volume. 2012;94:1839-44.
[87] Järvenpää J, Kettunen J, Soininvaara T, Miettinen H, Kröger H. Obesity has a negative impact on
clinical outcome after total knee arthroplasty. Scand J Surg. 2012;101:198-203.
[88] Krushell RJ, Fingeroth RJ. Primary Total Knee Arthroplasty in Morbidly Obese Patients: a 5- to 14-year
follow-up study. The Journal of arthroplasty. 2007;22:77-80.
[89] 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. The Journal of bone and joint surgery
American volume. 2007;89:33-8.
[90] Deshmukh RG, Hayes JH, Pinder IM. Does body weight influence outcome after total knee
arthroplasty? A 1-year analysis. The Journal of arthroplasty. 2002;17:315-9.
[91] Napier RJ, O'Brien S, Bennett D, Doran E, Sykes A, Murray J, et al. Intra-operative and short term
outcome of total knee arthroplasty in morbidly obese patients. The Knee. 2014.
[92] Ersozlu S, Akkaya T, Ozgur AF, Sahin O, Senturk I, Tandogan R. Bilateral staged total knee arthroplasty
in obese patients. Arch Orthop Trauma Surg. 2008;128:143-8.
[93] Bordini B, Stea S, Cremonini S, Viceconti M, De Palma R, Toni A. Relationship between obesity and
early failure of total knee prostheses. BMC musculoskeletal disorders. 2009;10:29.
[94] Collins RA, Walmsley PJ, Amin AK, Brenkel IJ, Clayton RA. Does obesity influence clinical outcome at
nine years following total knee replacement? J Bone Joint Surg Br. 2012;94:1351-5.
[95] 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;88:1321-6.
[96] 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. The Journal of arthroplasty.
2009;24:89-94, e1-3.
[97] Buchbinder R, Richards B, Harris I. Knee osteoarthritis and role for surgical intervention: lessons
learned from randomized clinical trials and population-based cohorts. Current opinion in rheumatology.
2014;26:138-44.
[98] 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. The Journal of bone and joint surgery American
volume. 2012;94:1501-8.
[99] Nunez M, Lozano L, Nunez E, Sastre S, Luis Del Val J, Suso S. Good quality of life in severely obese
total knee replacement patients: a case-control study. Obes Surg. 2011;21:1203-8.
[100] Jones CA, Cox V, Jhangri GS, Suarez-Almazor ME. Delineating the impact of obesity and its
relationship on recovery after total joint arthroplasties. Osteoarthritis and cartilage / OARS, Osteoarthritis
Research Society. 2012;20:511-8.
[101] Yeung E, Jackson M, Sexton S, Walter W, Zicat B, Walter W. The effect of obesity on the outcome of
hip and knee arthroplasty. Int Orthop. 2011;35:929-34.
[102] Murray DW, Pandit H, Weston-Simons JS, Jenkins C, Gill HS, Lombardi AV, et al. Does body mass
index affect the outcome of unicompartmental knee replacement? The Knee. 2013;20:461-5.
[103] Hawker G, Wright J, Coyte P, Paul J, Dittus R, Croxford R, et al. Health-related quality of life after
knee replacement. The Journal of bone and joint surgery American volume. 1998;80:163-73.
[104] Moran M, Walmsley P, Gray A, Brenkel IJ. Does body mass index affect the early outcome of
primary total hip arthroplasty? The Journal of arthroplasty. 2005;20:866-9.
[105] 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. The Journal of Bone and Joint
Surgery. 2003;85:52-6.
[106] Pfefferle KJ, Gil KM, Fening SD, Dilisio MF. Validation study of a pooled electronic healthcare
database: the effect of obesity on the revision rate of total knee arthroplasty. European journal of
orthopaedic surgery & traumatology : orthopedie traumatologie. 2014.
[107] Hamoui N, Kantor S, Vince K, Crookes PF. Long-term outcome of total knee replacement: does
obesity matter? Obes Surg. 2006;16:35-8.
[108] Bourne RB, McCalden RW, MacDonald SJ, Mokete L, Guerin J. Influence of patient factors on TKA
outcomes at 5 to 11 years followup. Clinical orthopaedics and related research. 2007;464:27-31.
[109] Spicer DD, Pomeroy DL, Badenhausen WE, Schaper LAJ, Curry JI, Suthers KE, et al. Body mass index
as a predictor of outcome in total knee replacement. Int Orthop. 2001;25:246-9.
[110] Gillespie GN, Porteous AJ. Obesity and knee arthroplasty. The Knee. 2007;14:81-6.
[111] Wang YC, McPherson K, Marsh T, Gortmaker SL, Brown M. Health and economic burden of the
projected obesity trends in the USA and the UK. The Lancet. 2011;378:815-25.
[112] Dunbar MJ, Howard A, Bogoch ER, Parvizi J, Kreder HJ. Orthopaedics in 2020: predictors of
musculoskeletal need. The Journal of bone and joint surgery American volume. 2009;91:2276-86.
[113] Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee
arthroplasty in the United States from 2005 to 2030. The Journal of bone and joint surgery American
volume. 2007;89:780-5.
[114] James PT, Leach R, Kalamara E, Shayeghi M. The worldwide obesity epidemic. Obes Res. 2001;9
Suppl 4:228S-33S.
[115] Kim SH. Morbid obesity and excessive hospital resource consumption for unilateral primary hip and
knee arthroplasty. The Journal of arthroplasty. 2010;25:1258-66.
[116] Hebert CK, Williams RE, Levy RS, Barrack RL. Cost of treating an infected total knee replacement.
Clinical orthopaedics and related research. 1996;331:140-5.
[117] Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update.
Arthritis & Rheumatism. 2000;43:1905-15.
[118] Pendleton A, Arden N, Dougados M, Doherty M, Bannwarth B, Bijlsma JW, et al. EULAR
recommendations for the management of knee osteoarthritis: report of a task force of the Standing
Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Annals of the
rheumatic diseases. 2000;59:936-44.
[119] Coombes R. Rationing of joint replacements raises fears of further cuts. BMJ. 2005;331:1290.
[120] Wadden TA. Treatment of obesity by moderate and severe caloric restriction. Results of clinical
research trials. Ann Intern Med. 1993;119:688-93.
[121] Karlsson J, Sjöström L, Sullivan M. Swedish obese subjects (SOS)--an intervention study of obesity.
Two-year follow-up of health-related quality of life (HRQL) and eating behavior after gastric surgery for
severe obesity. Int J Obes Relat Metab Disor. 1998;22:113-26.
[122] Rosal MC, Ayers D, Li W, Oatis C, Borg A, Zheng H, et al. A randomized clinical trial of a peri-
operative behavioral intervention to improve physical activity adherence and functional outcomes
following total knee replacement. BMC musculoskeletal disorders. 2011;12:226.