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obesity_is_fueling_a_rise_in_joint_replacement_surgeries/
Obesity is fueling a rise in joint-replacement surgeries
Increased obesity fuels a rise in joint-replacement surgeries
By Liz Kowalczyk, Globe Staff | July 18, 2006
Surgery to replace damaged knees and hips with artificial joints has become so common among active baby boomers that it almost seems like a badge of honor. But evidence is growing that it's not only skiers and joggers fueling the explosion of operations, but obese Americans.
Some hospitals estimate that half to two-thirds of their patients having joint-replacement surgery are overweight or obese, and these patients are posing added challenges for medical teams.
They appear to suffer more complications during and after surgery, require more costly rehabilitation, and, because of the strength it takes to manipulate their bones, can even create physical risks for surgeons. Heavy patients face increased risks of blood clots, wound infections, and pneumonia, according to studies, causing some surgeons to turn away patients unless they lose weight.
Three in 10 American adults, 66 million people, are considered obese, up from 23 percent a decade ago, according to the federal Centers for Disease Control and Prevention. And because this group is believed to have a higher incidence of osteoarthritis than people of normal weight, obese Americans may suffer a joint-replacement epidemic, in addition to increased rates of diabetes and high blood pressure.
``Ten to 15 years from now, we're going to be faced with even more obese patients," said Dr. Thomas Turgeon, a Canadian orthopedic surgeon who recently found that obese patients undergoing hip replacements experienced 2 1/2 times as many complications as normal-weight and somewhat-overweight patients.
Obese patients also were 2.6 times more likely to be discharged to a rehabilitation facility. ``We have to figure out how to address these issues before the surgery," Turgeon said.
The number of hip replacement operations done annually in the United States increased 75 percent to 217,000 between 1993 and 2003, while the number of knee replacements grew 133 percent to 402,000, says the American Academy of Orthopaedic Surgeons. At the organization's annual meeting in March, researchers predicted that the number of operations will grow to 572,000 and 3.5 million, respectively, by 2030, as a result of growing acceptance of the operations, the aging of the population, active baby boomers, and increasing obesity.
While there are few detailed analyses of how much obesity contributes to the overall trend, one Canadian study of 17,000 patients found that 9 in 10 who had knee replacements and 7 in 10 who had hip replacements in that country in 2004 were overweight.
Scientists at the Massachusetts Institute of Technology and other institutions that study osteoarthritis suspect that obese people are damaging their knees and hips in ways that go beyond the additional weight they carry . One MIT lab is studying whether certain proteins that are abundant in fat tissue cause chronic inflammation and destroy cartilage in the joints.
In Boston, New England Baptist Hospital does the most joint-replacement operations, and it estimates that more than 70 percent of its orthopedic surgery patients are overweight or obese. About 35 percent of US adults age 20 and over are overweight, and another 30 percent are obese, according to the CDC.
``Weekend warriors are not the majority of patients we're operating on," said Diane Gulczynski, the hospital's senior vice president of patient care services and chief nursing officer.
Concerned about an increased rate of infection among hip- and knee-replacement patients, Gulczynski decided last year to search these patients' medical records for patterns. She discovered that doctors were operating on a high percentage of obese patients and that those patients accounted for a disproportionate share of infections.
In one recent three-month period, 39 percent of the hospital's orthopedic surgery patients were obese, with a body mass index of more than 30, accounting for 44 percent of the wound infections. Obese surgery patients are more prone to wound infections for various reasons, doctors said, including difficulty keeping folds of skin clean and high rates of diabetes, hypertension, and heart disease.
Because of the higher risk of infection for these patients, the hospital is implementing more aggressive infection-prevention measures, such as more carefully controlling obese patients' glucose levels during and after surgery. Soon, all patients will be tested for a certain antibiotic-resistant bacteria that can cause wound infections; those who test positive will take a special antibiotic before and during surgery.
``You don't want to eliminate obese patients from having operations, because you'd be eliminating so many people," Gulczynski said. ``You want to give them a chance for a better quality of life. And they're not going to be able to lose weight beforehand if they can barely walk."
Indeed, overweight patients with arthritis in their hips or knees often find themselves in a no-win situation.
Guy Snowden, 60, has struggled with his weight for years. When he was 50 pounds overweight, his knees began to ache. As the pain grew worse, he stopped going for walks, playing golf, or even going to the movies. By the time he was ready to have his left knee replaced four years ago, he was 100 pounds overweight.
Dr. Richard Scott, chief of joint-replacement services at Brigham and Women's Hospital and New England Baptist, did the operation and then, a year ago, replaced Snowden's right knee. After each operation, Snowden spent about a week in a rehabilitation facility.
Since the last operation, Snowden has resumed walking and golfing and has lost 20 pounds.
``Dr. Scott said it was key to try to get some weight off, that the knees would last longer," Snowden said. ``I am really hoping these will go the distance."
Scott said that when people walk, they place a force equal to three times their body weight on their knees and hips; that force grows to five times their body weight when climbing or descending stairs. So if a person is 20 pounds overweight, that can burden joints with 100 extra pounds.
Scott said he sets eligibility limits on patients seeking surgery. If they are very obese and have other health problems, he'll give them ``a tentative date for surgery a year away maybe."
``I tell them: `If you lose so much weight . . . then I will fill my end of the bargain, and we'll go ahead with your surgery. If you don't do it, you're telling me you're not motivated,' " Scott said.
The purpose is to decrease the risk of surgery and to improve the chances of success. Obese patients generally experience as much pain relief as normal-weight patients after surgery, studies show. But the long-term picture is cloudier. According to a 2004 study at Johns Hopkins University School of Medicine in Baltimore, 99 percent of knee replacements in nonobese patients were successful 6 1/2 years after surgery. The success rate dropped to 88 percent for obese patients.
But, Scott conceded, most patients don't drop much weight. Given the risks for patients, he said he would not operate on someone who weighs 400 pounds or more. The operation would be difficult for him to perform, after tearing his rotator cuff several years ago from the sheer exertion of trying to expose the bone of a morbidly obese patient during surgery.
Liz Kowalczyk can be reached at kowalczyk@globe.com.
© Copyright 2006 Globe Newspaper Company.
Xeno Muller, Olympic gold and silver medalist, indoor rowing, rowing technique.
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