t h e s u r g e o n 1 6 ( 2 0 1 8 ) 4 0 e4 5

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The Surgeon, Journal of the Royal Colleges
of Surgeons of Edinburgh and Ireland
www.thesurgeon.net

A comparison of outcomes in morbidly obese,

obese and non-obese patients undergoing primary
total knee and total hip arthroplasty

Angela H. Deakin*, Aghimien Iyayi-Igbinovia, Gavin J. Love

Department of Orthopaedics, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, United
Kingdom

article info abstract

Article history: Background: Obesity is a growing public health issue with the prevalence of morbid obesity,
Received 28 January 2016 (Body Mass Index (BMI)
40 kg/m2) increasing. There is some evidence these patients have
Received in revised form more peri- and post-operative complications and poorer outcomes when undergoing
10 October 2016 arthroplasty procedures. This audit aimed to determine and compare the outcomes of non-
Accepted 24 October 2016 obese, obese and morbidly obese patients undergoing arthroplasty at our institution.
Available online 27 January 2017 Method: This was a retrospective audit of patients from our institution who had undergone
total knee (TKA) or total hip arthroplasty (THA) in 2009. Data collected were: age, gender,
Keywords: BMI, length of stay (LOS), Oxford knee or hip score (OKS/OHS), satisfaction and complica-
Morbid obesity tions up to two years post operation. Patients were divided into three groups: BMI < 30, BMI
Total knee arthroplasty 30e40 and BMI > 40. Outcomes for each BMI group were compared.
Total hip arthroplasty Results: 1014 TKA and 906 THA operations were included. When compared to obese and
Patient satisfaction non-obese patients, morbidly obese patients undergoing TKA had a mean LOS one day
Complications longer, a mean OKS four points lower and higher rates of postoperative problems, 37% vs.
21%. For THA patients there was no difference in LOS, OHS score was two points lower for
each increasing BMI category and postoperative problems increase from 25% for non-obese
to 31% for obese and 38% for morbidly obese patients.
Conclusion: These results will be useful in informing obese patients of their potential out-
comes following TKA or THA. These patients can then make a more informed choice before
proceeding with arthroplasty.
© 2016 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and
Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

I ¼ 30e34.99, Class II ¼ 35e39.99, Class III ¼
40.1 The defini-

Introduction tion of severe or morbid obesity has varied, with NIH defining
it as BMI > 35 in 19912 and NICE defining it as BMI > 40 in 2002.3
The World Health Organization defines obesity as a Body Mass Within the UK morbid obesity is more usually used to refer to
Index (BMI)
30 kg/m2 and lists three classes of obesity; Class BMI > 40. The prevalence of obesity in the United Kingdom is

* Corresponding author.
E-mail address: angela.deakin@gjnh.scot.nhs.uk (A.H. Deakin).
http://dx.doi.org/10.1016/j.surge.2016.10.005
1479-666X/© 2016 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.
Published by Elsevier Ltd. All rights reserved.
 t h e s u r g e o n 1 6 ( 2 0 1 8 ) 4 0 e4 5
rising, with a trebling in the number of obese people in En-
gland and Wales over the last 20 years.4 Recent meta-analyses
have shown complications are higher for obese patients after
total knee arthroplasty (TKA)5,6 and that in total hip arthro-
plasty (THA) there were more complications and worse
functional outcomes.7
However much of the literature has been carried out on:
historical cohorts with a wide range of operation dates
meaning that they also reflect substantial changes in practice
and variations of proportions of obese patients within the
population during the study; cohorts where there are only
small numbers of morbidly obese patients or comparisons
have not been made across all obesity groups i.e. morbidly
obese are compared to non-obese; only TKA or THA cohorts or
these have been analysed as total joint arthroplasty so there is
little information comparing TKA and THA arthroplasty from
the same practice. Therefore the aims of this audit were to
determine the function, satisfaction and complications within
two years of operation for all patients undergoing arthroplasty
at our institution within a single calendar year. Knees and
hips would be treated separately and the outcomes compared
based on obesity groups (non-obese, obese and morbidly
obese). This would provide information on outcomes and
complications for obese and morbidly obese patients and
highlight any difference between knee and hip patients in
order to guide future practice.
Methodology
This was a retrospective audit carried out under the Clinical
Governance procedures of our institution, including Caldicott
Guardian approval for the use of patient data. As this study
was purely a retrospective review of data already collected as
part of each patient's clinical treatment it did not require
ethical review. The selection criteria for the study were having
had either an elective primary total knee arthroplasty (TKA) or
primary total hip arthroplasty (THA) carried out by any of the
nine consultant orthopaedic surgeons working at our insti-
tution in 2009, giving an unselected consecutive series. Uni-
condylar knee replacements, emergency procedures and
revision operations were excluded.
A list of patients meeting the selection criteria was collated
from both the hospital and departmental databases. All data
for any events or appointments up to two years following
operation were reviewed. For each patient the following data
were collected either from hospital databases or case notes:
age, gender, BMI, length of stay (LOS e patients were admitted
on day prior to operation), Oxford knee scores (OKS) or Oxford
hip scores (OHS) (0e48 scale, 48 being best outcome) and pa-
tient satisfaction, both from the one year follow up, which was
the standard clinical care review point when these data were
recorded. All post-operative appointments up to two years
post-surgery were reviewed for any indication of problems
relating to surgery. This included any problems reported by
patients, those identified by the independent Arthroplasty
Service which carried out both routine and addition follow-up
appointments and those identified via consultant review.
Standard appointments were at six weeks and one year post-
operative for TKAs, and three months and one year for THAs.
In addition all complications leading to readmission to any
41
hospital in Scotland up to two years after surgery were ob-
tained from NHS Information Services Division (ISD). The
following complications related to surgery were identified:
Acute Myocardial Infarction (AMI); Cerebrovascular accident
(CVA); death; Deep Vein Thrombosis (DVT)/Pulmonary Em-
bolism (PE); dislocation (THA only); infection; revision surgery.
Readmissions for other reasons were grouped under “other”.
Patients were divided into three groups: those with
BMI < 30 (non-obese), patients with BMI of 30e40 (obese) and
those with BMI > 40 (morbidly obese). Outcomes for each
group were compared using appropriate statistical tests (Chi-
square for categorical/ordinal data, median test for non-
parametric continuous data and ANOVA for parametric
continuous data).
Results
Total knee arthroplasty
A total of 1014 TKA operations were included. Fifty-four
percent of the cohort was female, mean age was 68.6 years
(SD 8.8, range 41e96) and mean BMI was 32.0 (SD 5.4, range
16e55). When grouped by BMI 35.8% of patients were not
obese (BMI < 30), 54.7% were obese (BMI of 30e40) and 7.7%
were morbidly obese (BMI > 40). Patient in the morbidly obese
group were significantly younger and more likely to be female
compared to those in other BMI groups (p < 0.001). The com-
parison of demographics across BMI groups is given in Table 1.
The median LOS was 5 days in both the non-obese and
obese groups but was significantly longer at 6 days in the
morbidly obese group (median test p ¼ 0.042) (Table 2). At one
year follow-up the mean OKS was 38 in both non-obese and
obese groups, but was 34 in the morbidly obese group which
was significantly lower (ANOVA p < 0.001) (Table 2). In the
morbidly obese group fewer patients were very satisfied
although this was only approaching significance (72% vs, 84%
and 84%, Chi-squared p ¼ 0.054) but there was no significant
difference in the numbers unsure or dissatisfied (3% vs, 6%
and 6%, Chi-squared p ¼ 0.635) (Table 2).
In the morbidly obese group 37% of patients had a
complication (requiring readmission) or problem (dealt with
through outpatient clinic) related to surgery, which was
significantly more than the non-obese group, 21%, and the
obese group, 21% (Chi-square p ¼ 0.004) (Table 3). The majority
of these problems were in the immediate post-operative
period and resolved satisfactorily. Within the first two years
after operation 14% of morbidly obese patients (11 patients)
were readmitted to hospital for any reason compared to 8% of
non-obese and 8% of obese patients. For readmissions related
to surgery these were 12% (9 patients) in the morbidly obese
Table 1 e Demographics of the different BMI groups for
TKA; Data presented as mean (SD) [range].
BMI  30 30 < BMI  40 BMI > 40
n 381 555 78
Gender 47% female 55% female 78% female
Age 71.3 (8.7) [42e96] 67.5 (8.6) [41e86] 63.7 (7.5) [48e77]
42 t h e s u r g e o n 1 6 ( 2 0 1 8 ) 4 0 e4 5

The median LOS was 5 days in all BMI groups (median test
Table 2 e Outcomes of BMI groups for TKA. Data
p ¼ 0.583) (Table 5). At one year follow-up the mean OHS were
presented as median [IQR] {range} or mean (SD) [range].
significantly different between groups, being 43 for the non-
BMI  30 30 < BMI  40 BMI > 40
obese group, 41 in the obese group and 39 in the morbidly
n ¼ 381 n ¼ 555 n ¼ 78
obese group (ANOVA p ¼ 0.001) (Table 5). In the morbidly
Length of stay 5 [3] {3e31} 5 [2] {2e59} 6 [3] {3e18} obese group 87% of patients were very satisfied and 3% were
(days)
unsure or dissatisfied which was not significantly different
1 year OKS 38 (8) [48e12] 38 (8) [48e5] 34 (10) [48e4]
1 year satisfaction (%)
when compared to 90% and 2%, and 91% and 2% in the non-
Very satisfied 83.8 84.3 72.1 obese and obese groups respectively (Chi-squared p ¼ 0.955)
Satisfied 9.8 9.8 24.6 (Table 5).
Unsure 3.7 4.9 3.3 Significantly more patients in the morbidly obese group,
Dissatisfied 2.8 1.1 0.0 38%, had a complication or problem compared to 25% in the
non-obese group and 31% in the obese group (Chi-square
p ¼ 0.047) (Table 6). The majority of these problems were in the
Table 3 e Number of patients with problems and early post-operative period and resolved satisfactorily. Within
complications related to their TKA operation by BMI the first two years after operation 15% (6 patients) from the
group. morbidly obese group were readmitted to hospital for any
BMI  30 30 < BMI  40 BMI > 40 reason compared to 9% of non-obese and 10% of obese pa-
n ¼ 381 n ¼ 555 n ¼ 78 tients. For readmissions related to surgery in the morbidly
Complication or problem within first two years obese group this was 8% (3 patients) compared to 7% for non-
Total 80 (21%) 117 (21%) 29 (37%) obese and 8% for obese patients which was not significantly
Post-operative problems dealt with via out-patient clinic different (Chi-square p ¼ 0.914) (Table 4).
Wound/SSSI 14 (4%) 17 (3%) 3 (4%)
Stiffness 4 (1%) 5 (1%) 3 (4%)
Haematoma 0 (0%) 0 (0%) 1 (1%)
Swelling 5 (1%) 12 (2%) 7 (9%) Discussion
Pain 27 (7%) 37 (7%) 5 (6%)
Other 4 (1%) 4 (1%) 1 (1%) This retrospective audit examined outcomes for patients with
Major complications related to surgery requiring re-admission different levels of obesity in patients who had TKA or THA
AMI 1 (<1%) 3 (<1%) 0 (0%) carried out at our institution. We found that high BMI patients
CVA 0 (0%) 0 (0%) 0 (0%)
were more likely to be younger and female, which has already
Death 0 (0%) 0 (0%) 0 (0%)
been widely reported.8e13 For those undergoing TKA we found
DVT/PE 2 (<1%) 10 (2%) 2 (3%)
Infection 6 (2%) 7 (1%) 3 (4%) morbidly obese patients (BMI > 40) had poorer outcomes than
Revision 4 (1%) 10 (2%) 1 (1%) obese and non-obese, which had very similar outcomes.
Other 13 (4%) 12 (2%) 3 (4%) However for those undergoing THA there were differences in
outcomes between all groups, with each increasing BMI group
doing slightly worse.
group compared to 7% for non-obese and 8% for obese pa-
tients (Chi-square p ¼ 0.358) (Table 3).
Total knee arthroplasty

Total hip arthroplasty The literature varies as to whether higher BMI patients have a
longer post-operative stay after TKA with some authors
There were 906 THA operations included. Sixty-three percent showing an increase14 and others not8,15,16 although Napier
of the cohort was female, mean age was 68 years (SD 10, range et al.15 used the lower cut off of BMI > 35 and in Krushell and
34e91) and mean BMI was 29.7 (SD 5.3, range 16e49). When Fingeroth16 patients were not discharged directly to home.
grouped by BMI 57.0% were not obese (BMI < 30), 38.6% were This audit supports the former with the median length of stay
obese (BMI of 30e40) and 4.4% were morbidly obese (BMI > 40). for morbidly obese patients being a day longer than others. We
Patients in the morbidly obese group were significantly
younger (p < 0.001) and more likely to be female, although this
only approached statistical significance (p ¼ 0.077). The Table 5 e Outcomes of BMI groups for THA. Data
comparison of demographics across BMI groups is given in presented as median [IQR] {range} or mean (SD) [range].
Table 4. BMI  30 30 < BMI  40 BMI > 40
n ¼ 516 n ¼ 350 n ¼ 40
Length of stay 5 [3] {2e71} 5 [3] {3e31} 5 [4] {3e57}
Table 4 e Demographics of the different BMI groups for (days)
THA; Data presented as mean (SD) [range]. 1 year OHS 43 (7) [48e9] 41 (8) [48e7] 39 (8) [48e15]
1 year satisfaction (%)
BMI  30 30 < BMI  40 BMI > 40
Very satisfied 90.3 91 86.5
N 516 350 40 Satisfied 7.4 7.0 10.8
Gender 65% female 59% female 72% female Unsure 1.8 1.3 2.7
Age 70 (10) [38e91] 66 (10) [34e 87] 63 (6) [38e79] Dissatisfied 0.5 0.7 0.0
 t h e s u r g e o n 1 6 ( 2 0 1 8 ) 4 0 e4 5 43

meant to be joint specific score it may well be affected by

Table 6 e Number of patients with problems and
overall health and therefore very high BMI patients may report
complications related to their THA operation by BMI
group. a lower score due to general difficulties with movement rather
than their knee replacement having poorer function. A more
BMI  30 30 < BMI  40 BMI > 40
in-depth study looking at actual knee function would be
n ¼ 516 n ¼ 350 n ¼ 40
required to ascertain this.
Complication or problem within first two years
Our institution is a high volume dedicated elective lower
Total 129 (25%) 110 (31%) 15 (38%)
Post-operative problems dealt with via out patient clinic
limb arthroplasty centre and in general our patients report
Wound/SSSI 21 (4%) 33 (9%) 4 (10%) high levels of satisfaction. However this study has shown that
Stiffness 5 (1%) 2 (<1%) 0 (0%) even within this environment morbidly obese patients are less
Swelling 8 (2%) 6 (2%) 2 (5%) likely to be very satisfied which has been shown before.16
Pain 13 (2%) 16 (5%) 1 (2%) However obese patients show similar levels of satisfaction to
Clicking or 5 (1%) 2 (<1%) 0 (0%)
non-obese. Further work looking specifically at what leads
clunking
patients to be very satisfied is required to understand why the
Trendelenburg 17 (3%) 7 (2%) 1 (2%)
gait very high BMI patients show lower satisfaction, however it
Heterotopic 1 (<1%) 2 (<1%) 0 (0%) could be due to the higher numbers of post-operative prob-
ossification lems seen in this group. However in this cohort dissatisfaction
Leg length 12 (2%) 9 (3%) 3 (7%) with TKA does not appear to be related to BMI.
discrepancy In this audit, we found a significantly higher rate of post-
Nerve palsy/foot 5 (1%) 2 (<1%) 0 (0%)
operative problems in the morbidly obese group compared
drop
to non-obese and obese patients, although we could not show
Other 6 (1%) 4 (1%) 1 (2%)
Major complications related to surgery requiring re-admission a difference in major complications, probably due to the lack
AMI 4 (1%) 0 (0%) 0 (0%) of power. The literature shows increased complications in
CVA 1 (<1%) 0 (0%) 0 (0%) both obese11,20 and morbidly obese patients11,15,16,18,19
Death 0 (0%) 0 (0%) 0 (0%) although one smaller study did not find this in BMI > 35 pa-
Dislocation 9 (2%) 5 (1%) 0 (0%) tients.9 It should also be noted that different studies use
DVT/PE 6 (1%) 6 (2%) 1 (2%)
different and sometimes more restrictive list of complica-
Infection 3 (<1%) 6 (2%) 1 (2%)
Revision 9 (2%) 9 (3%) 0 (0%)
tions. This might explain the different results seen as higher
Other 4 (1%) 1 (<1%) 1 (2%) BMI does seem to lead to more bleeding, wound and infection
problems and revisions6,16,20,21 but differences are not seen in
PE or mortality.20,21 When counselling morbidly obese pa-
believe this is the first cohort to look at length of stay in high tients before TKA the higher risks of post-operative problems
BMI patients where an enhanced recovery after surgery pro- should be discussed.
gramme was in place for all patients.17 The longer median
length of stay in the morbidly obese may indicate that these Total hip arthroplasty
patients are unable to benefit as much from the early mobi-
lisation and the more rapid rehabilitation that an enhanced As with TKA for THA the literature varies as to whether higher
recovery programme provides. The fact that the high BMI BMI patients have a longer post-operative stay with some
patients were younger might lead to expecting a shorter LOS authors showing an increase14 and others not12,22 although
but we did not find this indicating that the BMI was a stronger Michalka et al. used the lower cut off of BMI > 35.22 This audit
factor.14 supports the latter with the median length of stay for all pa-
A number of small studies have reported no significant tient groups being five days. We believe this is the first cohort
difference in outcome scores (such as OKS or Knee Society to look at length of stay in high BMI patients where an
Score) for TKA patients with higher BMIs15,18,19 but many enhanced recovery after surgery programme was in place for
indicate that obese6,9,20 and morbidly obese10,16 patients have all patients.17 This shows that, in contrast to the TKA patients,
lower (worse) outcomes although the clinical significance of an enhanced recovery program can provide the same results
some of the small changes seen for obese patients is ques- in higher BMI patients in terms of LoS. This may be due to the
tioned.6 Our findings would support the view that it is the very THA cohort generally having a lower BMI.
high BMI patients who are more likely to have poor outcomes, Our OHS scores showing a two point decrease between
rather than all the obese. There may be a number of reasons each group are very similar to those reported in the litera-
for the lower scores. There is evidence that high BMI patients ture12,13,23,24 and studies using the Harris Hip Score also
have on average a lower pre-operative functional level.10,16 showed worse outcomes for obese patients.7,25 Although
Therefore even if they gain the same improvement their these are low changes in OHS they do reach clinical signifi-
post-operative function will be less.10 Unfortunately we were cance of four points between the non-obese and morbidly
unable to assess improvement within our cohort. However obese. Also our data and other literature seem to indicate a
maybe caution should be exercised when relating post- linear trend to worse scores with increasing BMI.7,24 This
operative function between different ranges of BMIs. Ideally could indicate that, even though the THA population has a
pre-operative function should be known along with the pa- lower mean BMI, many patients may benefit from a reduction
tient's expectations in order to more accurately predict a in BMI before surgery unlike in TKA where it seems that obese
satisfactory post-operative outcome. Also although the OKS is patients have very similar outcomes to non-obese. It has been
44 t h e s u r g e o n 1 6 ( 2 0 1 8 ) 4 0 e4 5
reported that for short term follow up no difference in OHS are
seen but that obese patients had better improvement in
scores.22 As we did not have pre-operative OHS we were not
able to confirm whether or not high BMI patients had the same
or greater levels on improvement.
Again in contrast to the TKA patients we found similar
rates of satisfaction across all BMI groups which concur with
published results.22
In this audit, we found significant changes in the rate of
post-operative problems in the different BMI groups with the
morbidly obese group having the highest rates, although we
did not show a difference in major complications, which may
be due to the lack of power. The literature shows increased
complications in both obese7,23 and morbidly obese pa-
tients.13,21,25 One large study showed no difference in com-
plications but they assessed each complication individually
giving the study low power to find any differences and another
small study also showed no short term differences but again
would have had low power.12,22 It should also be noted that
different studies use different and sometimes more restrictive
list of complications. This might explain the different results
seen as higher BMI does seem to lead to more bleeding, wound
problems, infections, dislocations, DVT/PE and revisions but
not other complications.7,13,23,25 When counselling obese pa-
tients for THA the higher likelihood of post-operative prob-
lems should be discussed.
Summary
This study was a retrospective audit which stratified pa-
tients by BMI. This is an unselected consecutive series. The
audit did not collect information on the number of patients
who were declined surgery due to being medically unfit (as
defined by a consultant anaesthetist), or the BMI for those
patients. However during the time of the audit there was no
selection for joint replacement based on BMI so this cohort
should be an accurate representation of the whole popula-
tion who are able to undergo a joint replacement operation.
We have analysed TKA and THA separately whereas some
studies have combined total joint arthroplasties.14,21 This
has given lower numbers of morbidly patients in each
cohort (78 TKA and 40 THA) so reducing power to investigate
these patients but has allowed us to show the differences
with BMI for each operation. The use of data from one cal-
endar year from a single institution also reduces the power
of this audit to see statistically significant differences,
particularly in the THA group. However it does allow the
comparison of outcomes where all patients have received
the same standardised peri-operative care and there have
not been large variations in practice within the cohort being
analysed. As we found that the higher BMI patients tended
to be younger and female the differences in outcomes seen
may be in part due to this. However due to the small
numbers it was not possible to carry out multivariable lo-
gistic regression to isolate these effects. However as high
BMI patients have these characteristics the findings are
representative of this group even if the underlying cause is
also strongly linked to a different demographic character-
istic. A further limitation of our study was the unavailability
of pre-operative scores which makes it impossible to assess
and comment on changes in scores post-operatively. Finally
there are variations in the literature in the categorisation of
morbid obesity as either BMI > 35 kg/m2 or BMI > 40 kg/m2.
This makes interpretation and comparison of results more
difficult.
This study has provided information about how outcomes
and complications vary with obesity in a large unselected
cohort treated in a large specialist arthroplasty centre over a
single calendar year with the same standardised enhanced
recovery peri-operative care relevant to modern joint
replacement surgery. It therefore has high external validity,
particularly compared to other study designs, such as RCTs
and matched cohorts. Due to this it may provide more rele-
vant information as to current real world outcomes than some
of the historical literature. We found high BMI patients tend to
be younger than the general TKA or THA arthroplasty popu-
lation and are more likely to be female. This study also high-
lighted the differences between TKA and THA. In this cohort
TKA patients had a higher BMI than THA patients and the
results would seem to indicate that increasing BMI has a
negative effect on THA patients, moving from non-obese to
obese to morbidly obese whereas for TKA patients differences
are only really seen in the very high BMI patients. Due to the
variation in outcomes it would be useful to carry out a cost
benefit analysis on treating high BMI patients but this was
outside the remit of our audit. Our results will be useful in
informing obese patients of their potential outcomes
following TKA or THA. These patients can then make a more
informed choice before proceeding with arthroplasty.
Conflict of interest
The authors have no conflicts of interest to declare.
No financial support was received for this study.
Acknowledgements
The authors would like to thank Nadia Sciberras, Mohammed
Almustafa and Marie Anne Smith for their help with the data
collection and Mohammad Nickdel for his help with preparing
the manuscript.
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