Bariatric surgery and total knee/hip arthroplasty: an analysis of the impact of sequence and timing on outcomes

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Abstract

Background

Patients with morbid obesity may require both bariatric surgery and total knee/hip arthroplasty (TKA/THA). How to sequence these two procedures with better outcomes remains largely unstudied.

Methods

This cohort study extracted claims data on patients with an obesity diagnosis that received both bariatric surgery and TKA/THA surgery within 5 years of each other (Premier Healthcare database 2006–2019). Overall, 1894 patients received bariatric surgery before TKA or THA, while 1000 patients underwent TKA or THA before bariatric surgery. Main outcomes and measures include major complications (acute renal failure, acute myocardial infarction, other cardiovascular complications, sepsis/septic shock, pulmonary complications, pulmonary embolism, pneumonia, and central nervous system-related adverse events), postoperative intensive care unit utilization, ventilator utilization, 30-day readmission, 90-day readmission, 180-day readmission and total hospital length of stay after the second surgery. Regression models measured the association between the complications and sequence of TKA/THA and bariatric surgery.

Results

Undergoing TKA/THA before bariatric surgery (compared with the reverse) was associated with higher odds of major complications (7.0% vs 1.9%; adjusted OR 4.8, 95% CI 3.1, 7.6, p<0.001). Similar patterns were also observed for intensive care unit admission, ventilator use postoperatively, 30-day, and 90-day readmissions. Patients who received a second surgery within 6 months of their first surgery exhibited worse outcomes, especially among the TKA/THA first patient cohort. Major complication incidences occurred at 20.5%, 12.5%, 5.1%, 5.0%, 5.8% and 8.5% with time between TKA/THA and bariatric surgery at <6 months, 6 months–1 year, 1–2, 2–3, 3–4 and 4–5 years, respectively.

Conclusions

Patients who require both bariatric surgery and TKA/THA should consider bariatric surgery before TKA/THA as it is associated with improved outcomes. Procedures should be staged beyond 6 months.

Related collections

Most cited references 19

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Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases

R Deyo (1992)

Administrative databases are increasingly used for studying outcomes of medical care. Valid inferences from such data require the ability to account for disease severity and comorbid conditions. We adapted a clinical comorbidity index, designed for use with medical records, for research relying on International Classification of Diseases (ICD-9-CM) diagnosis and procedure codes. The association of this adapted index with health outcomes and resource use was then examined with a sample of Medicare beneficiaries who underwent lumbar spine surgery in 1985 (n = 27,111). The index was associated in the expected direction with postoperative complications, mortality, blood transfusion, discharge to nursing home, length of hospital stay, and hospital charges. These associations were observed whether the index incorporated data from multiple hospitalizations over a year's time, or just from the index surgical admission. They also persisted after controlling for patient age. We conclude that the adapted comorbidity index will be useful in studies of disease outcome and resource use employing administrative databases.

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Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence.

Liam A M Ryan, Lauren H Nicholas, J Birkmeyer … (2013)

Starting in 2006, the Centers for Medicare & Medicaid Services (CMS) has restricted coverage of bariatric surgery to hospitals designated as centers of excellence (COE) by 2 major professional organizations. To evaluate whether the implementation of the COE component of the national coverage decision was associated with improved bariatric surgery outcomes in Medicare patients. Retrospective, longitudinal study using 2004-2009 hospital discharge data from 12 states (n = 321,464 patients) of changes in outcomes in Medicare patients undergoing bariatric surgery (n = 6723 before and n = 15,854 after implementation of the policy). A difference-in-differences analytic approach was used to evaluate whether the national coverage decision was associated with improved outcomes in Medicare patients above and beyond existing time trends in non-Medicare patients (n = 95,558 before and n = 155,117 after implementation of the policy). Risk-adjusted rates of any complication, serious complications, and reoperation. Bariatric surgery outcomes improved during the study period in both Medicare and non-Medicare patients; however, this change was already under way prior to the CMS coverage decision. After accounting for patient factors, changes in procedure type, and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes after (vs before) implementation of the CMS national coverage decision for any complication (8.0% after vs 7.0% before; relative risk [RR], 1.14 [95% CI, 0.95-1.33]), serious complications (3.3% vs 3.6%, respectively; RR, 0.92 [95% CI, 0.62-1.22]), and reoperation (1.0% vs 1.1%; RR, 0.90 [95% CI, 0.64-1.17]). In a direct assessment comparing outcomes at hospitals designated as COEs (n = 179) vs hospitals without the COE designation (n = 519), no significant differences were found for any complication (5.5% vs 6.0%, respectively; RR, 0.98 [95% CI, 0.90-1.06]), serious complications (2.2% vs 2.5%; RR, 0.92 [95% CI, 0.84-1.00]), and reoperation (0.83% vs 0.96%; RR, 1.00 [95% CI, 0.86-1.17]). Among Medicare patients undergoing bariatric surgery, there was no significant difference in the rates of complications and reoperation before vs after the CMS policy of restricting coverage to COEs. Combined with prior studies showing no association of COE designation and outcomes, these results suggest that Medicare should reconsider this policy.

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Does bariatric surgery prior to lower limb joint replacement reduce complications?

S Woodcock, S. Müller, Stephen M. Reed … (2011)

Obesity is an increasing health concern in developed world. Bariatric surgery is considered in super-obese patients. Many of these patients will also require lower limb arthroplasty. This study was performed to investigate the complications of hip and knee replacement in patients who had bariatric surgery either before or after their joint replacement. Hospital episode statistics data for English NHS patients undergoing lower limb arthroplasty and bariatric surgery between 2005 and 2009 were analysed. The joint replacement-specific and general medical complications were compared between those undergoing joint replacement prior to bariatric surgery and vice versa, and also with the general English arthroplasty patient. One hundred and forty-three patients underwent bariatric surgery and joint replacement. Bariatric surgery was performed first in 53 and arthroplasty first in 90 patients. The mean age of obese patients was 9 years younger than the general arthroplasty population. Mean in-hospital stay was similar but general medical complications in obese patients appear to be less, possibly because of the lower age at the time of the procedure. Hip dislocation rate at 18 months was higher. Within the two obese groups wound infection rate was 3.5 times lower and readmission to hospital at 30 days appeared to be 7-times lower in patients who had bariatric surgery prior to joint replacement (p = 0.06). In this patient group, the risk of complications following joint replacement appears to be lower if bariatric surgery is performed first. 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.