The relationship between obesity and primary total knee replacement: A scoping review of the literature

This is an accepted manuscript of an article published by Elsevier in International Journal of Orthopaedic and Trauma Nursing, available online at: https://doi.org/10.1016/j.ijotn.2021.100850 The accepted version of the publication may differ from the final published version.Background Primary Total Knee Replacement (TKR) is one of the most commonly performed elective orthopaedic procedures globally. Many of the patients undergoing this type of surgery are overweight or obese. In the UK clinical commissioning groups have imposed arbitrary Body Mass Index (BMI) thresholds for TKR surgery. Many obese patients undergoing TKR believe they will lose weight following the procedure because of increased mobility. Aim This paper aims to present the findings of a scoping literature review about the relationship between obesity and primary TKR and to make recommendations for clinical practice, education and policy Methods A scoping literature review investigated the impact of BMI/body weight on the need for TKR, the impact of body weight and or BMI on patient outcomes following TKR; weight loss/gain following TKR and the implications of obesity on cost of TKR. Findings Seventy-one papers were included in the review. Seven studies reported statistically significant associations between increased BMI/obesity with the need for TKR. Thirty of the studies reported worse outcomes for obese patients compared to non-obese comparators. Forty of the studies reported no difference between obese and non-obese participants including some where outcomes of obese patients were better than non-obese comparators. Eight studies reported on changes to weight before and after TKR, 3 of the studies reporting a higher percentage losing weight than gaining weight and 4 studies reported obese patients gained weight. The 8th study reported morbidly obese patients largely returned to their baseline BMI postoperatively. Conclusion The findings of the review challenge the legitimacy of setting BMI thresholds to control access to TKR surgery. There is an urgent need to develop evidence based approaches to support weight loss and weight management for this group of patients. Obese patients undergoing TKR should receive specific information regarding potential additional risk of complications and poorer outcomes. There is a need for health promotion regarding the association of being overweight/ obese in young adulthood and developing osteoarthritis of the knee joints requiring TKR in middle and older age.Published versio

Maximum recovery after knee replacement - the MARKER study rationale and protocol

Background There is little scientific evidence to support the usual practice of providing outpatient rehabilitation to patients undergoing total knee replacement surgery (TKR) immediately after discharge from the orthopaedic ward. It is hypothesised that the lack of clinical benefit is due to the low exercise intensity tolerated at this time, with patients still recovering from the effects of major orthopaedic surgery. The aim of the proposed clinical trial is to investigate the clinical and cost effectiveness of a novel rehabilitation strategy, consisting of an initial home exercise programme followed, approximately six weeks later, by higher intensity outpatient exercise classes. Methods/Design In this multicentre randomised controlled trial, 600 patients undergoing primary TKR will be recruited at the orthopaedic pre-admission clinic of 10 large public and private hospitals in Australia. There will be no change to the medical or rehabilitative care usually provided while the participant is admitted to the orthopaedic ward. After TKR, but prior to discharge from the orthopaedic ward, participants will be randomised to either the novel rehabilitation strategy or usual rehabilitative care as provided by the hospital or recommended by the orthopaedic surgeon. Outcomes assessments will be conducted at baseline (pre-admission clinic) and at 6 weeks, 6 months and 12 months following randomisation. The primary outcomes will be self-reported knee pain and physical function. Secondary outcomes include quality of life and objective measures of physical performance. Health economic data (health sector and community service utilisation, loss of productivity) will be recorded prospectively by participants in a patient diary. This patient cohort will also be followed-up annually for five years for knee pain, physical function and the need or actual incidence of further joint replacement surgery. Discussion The results of this pragmatic clinical trial can be directly implemented into clinical practice. If beneficial, the novel rehabilitation strategy of utilising outpatient exercise classes during a later rehabilitation phase would provide a feasible and potentially cost-effective intervention to optimise the physical well-being of the large number of people undergoing TKR