Electronic Letters to:

Editorials: F. Horan Obesity and joint replacement J Bone Joint Surg Br 2006; 88-B: 1269-1271 [Abstract] [Full text] [PDF]

eLetters: Submit a response to this article

Electronic letters published:

Obesity a risk factor for joint replacement – an unresolved debate?

Michelle M Dowsey, Professor Peter F M Choong   (9 May 2007)

Influence of obesity on hip replacement

Manoj S Todkar   (25 January 2007)

Can the manufacturers' cautions on obesity be ignored?

Anish P. Sanghrajka, Alan E. White, Consultant Orthopaedic Surgeon   (12 December 2006)

Obesity a risk factor for joint replacement – an unresolved debate? 9 May 2007
Michelle M Dowsey, Registered Nurse Deptartment of Orthopaedics St. Vincent's Hosptial, Professor Peter F M Choong Send letter to journal: Re: Obesity a risk factor for joint replacement – an unresolved debate? michelle.DOWSEY{at}svhm.org.au Michelle M Dowsey, et al.	Sir, I read this editorial with interest. It is indeed unfortunate that a health authority proposed not to fund hip replacement in patients with a body mass index (BMI) greater than 30kg/m2. As Mr Horan's editorial points out, there have been no controlled trials assessing the influence of obesity on outcome following joint replacement.(1) For a funding body to consider withholding hip replacement on the grounds of obesity, it is imperative to have sound evidential support that obesity is indeed a risk factor. In addition to establishing any existence of risk, it would also be important to determine what the impact would be, financial or otherwise, if surgery was withheld from obese individuals requiring joint replacement. It would be interesting to speculate what the outcome of worsening functional decline in this group of patients would be. For instance, loss of function and general de-conditioning from untreated and worsening arthritis may in turn lead to worsening health and loss of independence. These issues in themselves could result in considerable financial burden to public health. The study by McLaughlin and Lee cited in this editorial, as well as others, report the lack of difference in outcome following joint replacement in obese and non-obese patients.1,2 However, there is evidence to contradict their findings. A prospective evaluation of 2884 patients by Namba et al found an increased risk for infection in obese patients undergoing joint replacement.3 These findings are supported by a recent observational study published in JBJS(A) by Patel et al.4 They concluded that obesity was an independent risk factor for post-operative infection following primary knee replacement. Given that current evidence argues both for and against obesity being a risk factor for joint replacement, the debate can only be resolved through a controlled trial. Only then can we move forward with regard to evaluating if there is a need for a separate treatment protocol for obese patients requiring joint replacement. M.M. Dowsey, RN BApplSc (Nursing) Clinical Research Nurse, Department of Orthopaedics, P.F.M. Choong, MBBS MD FRACS FAOrthA, Professor of Orthopaedics, Director of Orthopaedics, Department of Orthopaedics and Melbourne University, Department of Surgery, St. Vincent's Hospital, Australia. 1. McLaughlin JR, Lee KR. The outcome of total hip replacement in obese and non-obese patients at 10- to 18-years. J Bone Joint Surg [Br] 2006;88-B:1286-92. 2. Perka C, Labs K, Muschik M, Buttgereit F. The influence of obesity on perioperative morbidity and mortality in revision total hip arthroplasty. Arch Orthop Trauma Surg 2000;120:267-71. 3. Namba RS, Paxton L, Fithian DC, Stone ML. Obesity and perioperative morbidity in total hip and total knee arthroplasty patients. J Arthroplasty 2005;20(7 Suppl 3):46-50. 4. Patel VP, Walsh M, Sehgal B, et al. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg [Am] 2007;89-A:33-8.
Influence of obesity on hip replacement 25 January 2007
Manoj S Todkar, Orthopaedic Surgeon Todkar Hospital, Pune, India Send letter to journal: Re: Influence of obesity on hip replacement mtodkar{at}hotmail.com Manoj S Todkar	Sir, I read this paper with great interest. We carried out a study at the University of Dundee on the influence of obesity on acetabular orientation in total hip replacement (THR). We found that there is no statistically significant difference in the acetabular orientation of obese and non-obese patients. In clinical practice many surgeons feel that achieving proper acetabular orientation in obese patients is a difficult task. M.S. Todkar, Orthopaedic Surgeon, Todkar Hospital, Pune, India.
Can the manufacturers' cautions on obesity be ignored? 12 December 2006
Anish P. Sanghrajka, Specialist Registrar Dept of Trauma & Orthopaedics, Southend University Hospital, Alan E. White, Consultant Orthopaedic Surgeon Send letter to journal: Re: Can the manufacturers' cautions on obesity be ignored? anish{at}dr-anish.com Anish P. Sanghrajka, et al.	Sir, We read this editorial with great interest. It provided a comprehensive overview of the available evidence but we are concerned that it overlooked the product information provided by the implant manufacturers. Whilst Mr Horan argues that there is no evidence in the literature to suggest that prostheses implanted in obese patients are more likely to fail, this appears to be contradictory to the information provided by the implant manufacturers themselves. We have reviewed the product information and cautions of several prostheses used at our unit, and found that all advise caution with obese patients. Biomet Europe list obesity as a “factor likely to compromise the success of the implantation” in the product information provided with their total hip replacement. Depuy list “obesity or excessive patient weight” as a condition that tends to “impose severe loading on the affected extremity, thereby placing the patient at higher risk for failure of the hip/knee replacement”. The product information also advises that patients are informed that factors such as weight may significantly affect wear. We understand that similar cautions are provided by most prosthesis manufacturers. We are unsure of the implications of using implants in situations in which manufacturers advise caution, particularly if a patient suffers an early mechanical failure. We feel it is very important that surgeons be aware of these cautions, and consider them whenever planning surgery. In addition, we would advise that patients are made aware of the manufacturers’ cautions as part of the pre-operative counselling process. A.P. Sanghrajka, Specialist Registrar, A.E. White, Consultant Orthopaedic Surgeon, Department of Trauma and Orthopaedics, Southend University Hospital, Essex, UK.