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The effect of obesity and increasing age on operative time and length of stay
in primary hip and knee arthroplasty
B. Bradley, S. Griffiths, K. Stewart, G. Higgins, M. Hockings, D. Isaac
PII:
DOI:
Reference:
S0883-5403(14)00399-4
doi: 10.1016/j.arth.2014.06.002
YARTH 54027
To appear in:
Journal of Arthroplasty
Received date:
Revised date:
Accepted date:
10 April 2014
21 May 2014
3 June 2014
Please cite this article as: Bradley B, Griths S, Stewart K, Higgins G, Hockings M, Isaac
D, The eect of obesity and increasing age on operative time and length of stay in primary
hip and knee arthroplasty, Journal of Arthroplasty (2014), doi: 10.1016/j.arth.2014.06.002
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*Corresponding author:
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Mr Ben Bradley
Specialist Registrar in Trauma Orthopaedics
4 Hicks Close
Probus
Truro
Cornwall
TR2 4NE
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ben.bradley@hotmail.co.uk
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ABSTRACT
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surgery, recording age, Body Mass Index (BMI) and co-morbidities. The effect of
these on operative duration and length of stay (LOS) was analysed. For a 1 point
increase in BMI we expect LOS to increase by a factor of 2.9% and mean theatre time
to increase by 1.46 minutes. For a l-year increase in age, we expect LOS to increase
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by a factor of 1.2%. We have calculated the extra financial costs associated. The
current reimbursement system underestimates the financial impact of BMI and age.
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The results have been used to produce a chart that allows prediction of LOS following
lower limb arthroplasty based on BMI and age. This data is of use in planning
INTRODUCTION
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operating lists.
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has demonstrated both increases in the median age and the proportion of older people
in the UK population2.
It is well recognized that obesity is a risk factor for developing lower limb
osteoarthritis.3,4 While obesity leads to a future increased risk of both hip and knee
arthroplasty5, knees appears more susceptible to degenerative disease in the obese
patient6 with each unit of age-adjusted BMI associated with a 4% increase in knee
osteoarthritis7 and an odds ratio of developing osteoarthritis of 9.3 with a BMI in
excess of 30 Kg/M2 (4).
The National Joint Registry (NJR)8 supports this observation, demonstrating that the
number of elective primary hip and knee replacement procedures performed in obese
patients (BMI >30Kg/M2) is increasing. 26% of patients undergoing primary hip
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arthroplasty in 2011 were obese compared with 21% in 2004. 32% of patients that
received a total knee replacement (TKR) in 2011 were obese compared with 28% in
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20048.
The impact of obesity and increasing age on the outcome of joint replacement surgery
remains controversial. The current difficult financial climate has led to an increasing
drive towards reducing costs within the UK National Health Service (NHS) and, in a
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future where we are facing the use of Patient Reported Outcome Measures (PROMs)
data to reimburse Trusts on a Payment by results Basis (PbR), it is important that the
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Perceptions of poorer outcomes and increased financial costs associated with joint
replacement surgery in the obese patient has already lead to some Trusts within the
UK and abroad rationing hip and knee arthroplasty surgery, barring access to patients
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with a BMI over 30 Kg/M2 (9, 6). Despite increased complication rates, poorer implant
survivorship and potentially worse long-term functional outcomes, obese patients do
benefit from arthroplasty surgery10,11,12 It is therefore difficult to justify withholding
this surgery based on BMI alone. Performing hip and knee arthroplasty surgery in
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obese patients is associated with increased costs13,14 and it is important that Trusts
understand the reason for these increased costs, address any modifiable factors and
adjust tariffs accordingly in order to allow appropriate levels of financial
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remuneration.
In line with the ageing UK population the number of primary joint arthroplasties
performed in the elderly patient group is set to continue to increase and the financial
implication of this needs to be fully appreciated. In addition to this escalating
requirement for surgery, advanced patient age has been shown to be associated with a
slower post-operative rehabilitation15 and an increased length of stay 16,17,18 although
the extent of this appears variable.
In our orthopaedic unit there is a perception that operative time in hip and knee
replacement surgery takes longer in obese patients and these patients take longer to
recover resulting in an increased length of stay (LOS). There is good evidence that
operative time is longer in morbidly obese patients; however, the extent of the time
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difference is controversial19,20. It was our aim to quantify this in our unit to allow
appropriate planning of operative lists, preventing list over-runs and patient
cancellations. The evidence surrounding LOS in obese patients following arthroplasty
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surgery is less clear with some studies demonstrating significantly increased stays21,22
while others report no difference23,24.
We therefore aimed to assess the relationship between both operative duration and
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LOS for obese patients in our unit. The effect of increasing age on LOS was also
investigated with the aim being to use both BMI and age to pre-operatively predict
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METHODS
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We retrospectively reviewed all primary hip and knee arthroplasties performed in our
unit in a one year period (2010). Our unit forms part of a UK training hospital
managing a trauma and elective workload. Patients were identified through our
database (CSC Galaxy Surgery), and the case notes of each patient were reviewed.
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The operation notes for each procedure were reviewed and all complex primary
arthroplasty procedures were identified and excluded from this study. For total hip
replacements (THR) complex primaries were deemed to be procedures that required
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Each patients age was recorded, and their pre-operative BMI and co-morbidities were
identified from the anaesthetic assessment. Specific co-morbidity indexes or the ASA
grade had not been routinely documented at anaesthetic assessment and therefore the
individual co-morbidities for each patient were recorded. The case notes also revealed
the date of discharge and therefore the LOS for that patient.
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Our theatre administration system (CSC Galaxy Surgery) was interrogated in order to
reveal the theatre time (not including anaesthetic time) for each procedure. This time
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includes the time required to transfer the patient from the anaesthetic room, position
and drape the patient, perform the preoperative and postoperative checks, and move
the patient from theatres at the end of the case.
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To assess the impact of BMI on theatre time, we fitted a linear regression model on
theatre time, with effects for BMI and type of joint replacement (hip or knee). To
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assess the impact of BMI on length of stay, we fitted a linear regression model on logtransformed (base 10) length of stay, with effects for BMI, patient age, type of joint
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replacement and patient co-morbidities. Analyses were carried out using the software
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package R25
RESULTS
589 consecutive primary hip and knee arthroplasties were reviewed. This included
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305 THRs and 284 TKRs. 53 THRs and 30 TKRs were excluded following review of
the operation note, as they were considered to be complex primary joint replacements
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as defined above.
The total number of hip arthroplasties analysed was 252. The number of knee
arthroplasties analysed was 254. The patient cohort characteristics are shown in Table
1.
TABLE 1: Patient cohort characteristics
THR
TKR
Total
identified
305
284
Number
excluded
53
30
Involved in
study
252
254
Average
BMI
29.7
30.3
Average Age
71.9
71.5
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<50.5 50.555.5
6
7
3
5
55.560.5
16
21
60.565.5
28
43
Age
65.570.5
42
47
70.575.5
61
52
35.540.5
20
31
40.550.5
9
9
75.580.5
49
40
80.585.5
27
28
>50.5
8
0
85.590.5
13
14
>90.5
3
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THR
TKR
5
0
25.530.5
96
86
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THR
TKR
18.525.5
57
51
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16-18.5
BMI
30.535.5
57
77
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TABLE 2: expected theatre time (minutes) with 95% prediction intervals, for subgroups of BMI and type of joint replacement. Predictions are estimated at the midpoint of each group, except for the >40 BMI group, where the prediction is estimated
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Time
103.3913
109.9405
117.5812
124.8581
132.1349
151.0548
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BMI
16-18.5
18.5-25
25-30
30-35
35-40
>40
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at 50 kg/m2.
UPL
170.5369
176.8661
184.3841
191.6789
199.1051
219.0198
LPL
23.89519
30.69971
38.50471
45.80337
52.97049
70.99619
UPL
158.3628
164.6566
172.1331
179.3882
186.7748
206.5889
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BMI
16-18.5
18.5-25
25-30
30-35
35-40
>40
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Graph 1 demonstrates the relationship between BMI and operative time for both total
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hip replacements and total knee replacements. Error bars indicate 1 SEM.
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200
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160
140
120
Hips
Knees
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100
80
60
40
18.5-25
25-30
30-35
35-40
>40
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16-18.5
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180
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BMI
TABLE 3: expected length of stay (days) with 95% prediction intervals, for subgroups of BMI and type of joint replacement for a 70-year old patient with no comorbidities. Predictions are estimated at the mid-point of each group, except for the
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BMI
16-18.5
18.5-25
25-30
30-35
35-40
>40
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LOS
2.970315
3.428014
3.956241
4.565863
5.269423
6.627463
LPL
1.463407
1.693230
1.956394
2.257267
2.600737
3.252783
UPL
6.028925
6.940155
8.000354
9.235554
10.676520
13.503288
LOS
2.817077
3.251164
3.752139
4.330311
4.997574
6.285553
LPL
1.386257
1.604664
1.854880
2.141087
2.467966
3.088875
UPL
5.724712
6.587087
7.590006
8.757980
10.119972
12.790476
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The results of this study have been incorporated into separate charts for total hip and
total knee replacements which incorporate both BMI and age in order to predict the
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DISCUSSION
The effect of obesity and increasing age in hip and knee replacement surgery has been
extensively investigated and remains controversial.
Hip and knee arthroplasty surgery in the obese patient may be associated with
increased complications. Significantly higher rates of deep infection7,26 and superficial
wound infections10 have been reported. Long term implant survivorship is reduced
with higher rates of implant failure27,28 and revision surgery29 attributed to increased
wear rates with greater load application,30 and increased rates of aseptic loosening31
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and dislocation10 in obese THR patients. Other studies have not demonstrated a link
between complication rates and obesity, and the topic remains controversial.32,33
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The overall success of joint arthroplasty surgery in improving function and quality of
life is well reported34 and, despite increased complication rates, obese patients do
benefit from arthroplasty surgery4,35 showing a significant improvement in both
condition-specific and generic well-being scores10,11,12 However, it is not clear
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well-being scores between the obese and non-obese patient33,35,19 others show
significant differences in Knee Society and Harris Hip Scores32,11. It does appear,
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however, that obesity does not affect improvements in post-operative quality of life
scores10.
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Increasing age has been shown to result in a significantly increased LOS following
primary hip and knee replacement surgery16,17,18. This has been attributed to poorer
rehabilitation potential36 leading to slower rehabilitation times15 and increased co-
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This study has demonstrated that operative time and post-operative LOS increase
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significantly with increasing BMI in primary hip and knee arthroplasty surgery.
While other studies have reported increased operative times19,20 and length of stays in
the obese and morbidly obese patient groups21,22 we have been able to quantify this as
a linear relationship with each point increase in BMI resulting in an increased theatre
time of 1.46 minutes (p<0.0001) and the LOS increasing by a factor of 2.9%
(p<0.0001). These increases are the same independent of whether a primary hip or
knee arthroplasty is performed.
In agreement with other studies we have demonstrated that increasing age results in a
significantly increased LOS following primary joint arthroplasty. We have quantified
this, showing that a 10 year increase in age results in LOS increasing by a factor of
13%.
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Our study is a retrospective analysis of 506 consecutive patients undergoing simple
primary hip and knee arthroplasty and is potentially limited by the number and
varying grade of surgeons involved. We have analysed hip and knee replacements
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The results of this study potentially have important financial implications for the
NHS. It is well recognised that arthroplasty surgery within the United States in obese
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patients is associated with increased use of hospital resources and therefore higher
financial costs13,14. No study has accurately identified the cost of performing primary
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hip and knee replacements in patients with high BMI in the NHS.
Reports from the United States quantify the increased cost of THR as $299 in the
obese group and $1179 in the morbidly obese group13. The cost TKR is increased by
$256 and $821 in the obese and morbidly obese groups respectively13. These
increased costs are attributed to higher operating costs24 and slower patient
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rehabilitation21,22
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In our institution the cost of theatre time is estimated at 6.95 per minute. We
demonstrate that an increase in BMI of 1 point would result in an increased cost of
10.15 in terms of theatre time alone. For an increase in BMI of 5 points the increased
cost associating with increased surgical time would be 50.75; for a 10 point BMI
increase this would be 101.50; a 20 point increase leading to an increased cost of
203.
The increased surgical time associated with performing hip and knee arthroplasty in
patients with high BMI does not truly reflect the increased demands on theatre time
presented by these patients. These patients also present an anaesthetic challenge with
procedures often being technically more difficult and lengthy. Our data does not
include this additional anaesthetic time. Transferring and positioning processes are
also more difficult resulting in increased time utilisation.
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We believe this information is of use in planning operative lists. Patients with a high
BMI can be allocated additional theatre time directly related to their actual BMI,
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In terms of LOS we demonstrate that a 1 point increase in BMI results in the LOS
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Therefore a 1 point increase in BMI will result in an increased cost of 9.90 in terms
of bed occupancy; a 5 point BMI increase will lead to a 49.50 increase; a 10 point
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Again these figures do not reflect the true cost of a lengthened hospital admission in
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this patient group. The increased costs highlighted are due to bed occupancy alone
and do not include the increased costs associated with resource use during the
prolonged admission.
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We have produced charts which predict post-operative LOS following hip and knee
replacement surgery based on patient age and BMI. This provides the potential for
improved bed management, reducing cancellation of further elective procedures due
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In terms of primary TKR isolated obesity generates a HRG code of HB212B with a
tariff of 6405 as opposed to 5707 in the non-obese patient without other co-
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morbidites.
The PbR system therefore reimburses local healthcare Trusts an extra 305 for a
patient with isolated obesity undergoing THR and 698 for an obese patient with no
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The results of this study have suggested that a 1 point increase in BMI will present an
increased financial cost in the region of 20.05 for both primary THR and TKR in
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terms of bed occupancy and increased surgical time alone. The extra anaesthetic and
logistical challenges presented by these patients are likely to further increase theatre
time utilisation in addition to the increased utilisation of resources associated with a
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prolonged admission are likely to further increase financial impact. We have not
attempted to calculate the additional costs associated with treating the higher
complication rate in obese patients reported elsewhere. Our study would therefore
appear to underestimate the financial costs, but clearly it is important to ensure that
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This study demonstrates that the relationship between obesity and both increased
theatre time and increased LOS is linear and therefore with increasing levels of
obesity local healthcare trusts face spiralling financial costs. The current HRG tariff
system for THR and TKR does not reflect this with a standard extra payment awarded
when the BMI exceeds 30 Kg/M2. We feel that this simplistic system fails to
adequately reimburse Trusts. The increased resource utilisation by overweight
patients (i.e. BMI 25-30) is not recognised and the increased costs associated with
performing this surgery in the morbidly obese and heavier groups is underestimated
by this system.
The current PbR system also fails to recognise the increased length of stay presented
by the elderly population as highlighted in this study potentially leading to inadequate
levels of financial reimbursement to Local Healthcare Trusts.
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CONCLUSIONS
We have demonstrated that there is a relationship between obesity and operative time,
and patient age and length of admission. This data will be of relevance when planning
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theatre lists and admission durations. The financial cost of operating on obese patients
can be offset by additional tariffs available, but any financial benefits may be negated
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