The association between body mass index and patient-reported outcome measures before and after primary total hip or knee arthroplasty: a registry
Corresponding Author
Jonathan S. Mulford MBBS (Hons), FRACS, Dip Clinical Trials
Launceston General Hospital, University of Tasmania, Tamar Valley Orthopaedics, Newstead, Tasmania, Australia
Correspondence
Prof Jonathan S. Mulford, Tamar Valley Orthopaedics 77 Elphin Road Newstead 7250 Tasmania, Australia.
Email: [email protected]
Contribution: Conceptualization, Formal analysis, Investigation, Methodology, Writing - original draft, Writing - review & editing
Search for more papers by this authorIlana Ackerman BPhysio (Hons), PhD
Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, School of Public Health and Preventative Medicine, Monash University, Monash, Victoria, Australia
Contribution: Formal analysis, Methodology, Writing - review & editing
Search for more papers by this authorCarl Holder MBiostat
South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
Contribution: Data curation, Formal analysis, Methodology, Writing - review & editing
Search for more papers by this authorKara S. Cashman BSc (Hons), Grad. Dip Math. Stats
South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
Contribution: Data curation, Formal analysis, Methodology, Writing - review & editing
Search for more papers by this authorStephen E. Graves MBBS, DPhil (Oxon), FRACS(Orth), FAOrthA
Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, South Australia, Australia
Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
Contribution: Writing - review & editing
Search for more papers by this authorIan A. Harris MBBS, FRACS, MMed (Clin Epi), MSc (HDS), PhD
Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, South Australia, Australia
Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, South West Sydney Clinical School, The University of New South Wales Sydney, Sydney, New South Wales, Australia
Institute of Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
Contribution: Conceptualization, Formal analysis, Methodology, Project administration, Supervision, Writing - original draft, Writing - review & editing
Search for more papers by this authorCorresponding Author
Jonathan S. Mulford MBBS (Hons), FRACS, Dip Clinical Trials
Launceston General Hospital, University of Tasmania, Tamar Valley Orthopaedics, Newstead, Tasmania, Australia
Correspondence
Prof Jonathan S. Mulford, Tamar Valley Orthopaedics 77 Elphin Road Newstead 7250 Tasmania, Australia.
Email: [email protected]
Contribution: Conceptualization, Formal analysis, Investigation, Methodology, Writing - original draft, Writing - review & editing
Search for more papers by this authorIlana Ackerman BPhysio (Hons), PhD
Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, School of Public Health and Preventative Medicine, Monash University, Monash, Victoria, Australia
Contribution: Formal analysis, Methodology, Writing - review & editing
Search for more papers by this authorCarl Holder MBiostat
South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
Contribution: Data curation, Formal analysis, Methodology, Writing - review & editing
Search for more papers by this authorKara S. Cashman BSc (Hons), Grad. Dip Math. Stats
South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
Contribution: Data curation, Formal analysis, Methodology, Writing - review & editing
Search for more papers by this authorStephen E. Graves MBBS, DPhil (Oxon), FRACS(Orth), FAOrthA
Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, South Australia, Australia
Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
Contribution: Writing - review & editing
Search for more papers by this authorIan A. Harris MBBS, FRACS, MMed (Clin Epi), MSc (HDS), PhD
Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), Adelaide, South Australia, Australia
Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, South West Sydney Clinical School, The University of New South Wales Sydney, Sydney, New South Wales, Australia
Institute of Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
Contribution: Conceptualization, Formal analysis, Methodology, Project administration, Supervision, Writing - original draft, Writing - review & editing
Search for more papers by this authorAbstract
Background
The objective is to determine whether body mass index is associated with patient-reported expectations and well-being before primary total hip or total knee arthroplasty, and patient-reported outcomes 6 months after surgery.
Methods
Data were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Outcome measures included pre-operative expectations for post-operative mobility, joint pain and health, pre- and post-operative EQ-5D-5L, EQ-VAS, Oxford Hip/Knee Scores and joint pain scales, and post-operative perceived change and perceived satisfaction. Associations with BMI were assessed using chi-square tests, analysis of variance and Linear Mixed Models equations.
Results
Data were available for 12 816 primary THA patients and 20 253 primary TKA patients. Pre-operatively, patients in higher BMI categories were significantly more likely to expect ongoing problems with mobility, more joint pain and poorer health following surgery (P<0.01 for all analyses). For arthroplasty patients, higher BMI was associated with poorer pre-operative and post-operative scores for all measures. BMI was positively associated with improvements in EQ-5D, OHS/KS and joint pain. While between-group differences were statistically significant, many were small in magnitude. There was no association between BMI and patient-perceived change or satisfaction after arthroplasty.
Conclusion
Patients undergoing THA/TKA, higher BMI was associated with lower pre-operative expectations, poorer well-being before surgery, and worse scores after surgery. Patients who were obese demonstrated comparable satisfaction with their operated joint, compared with non-obese patients. BMI was associated with greater pre- to post-operative improvements in outcome scores for EQ-5D, VAS knee, OHS/OKS and joint pain but these differences may not be clinically important.
Conflict of interest
None declared.
References
- 1 Australian Institute of Health and Welfare. Overweight and Obesity in Australia: A Birth Cohort Analysis. Cat. no. PHE 215. Canberra: AIHW. [Cited 7 Feb 2023] Available from URL, 2017. https://www.aihw.gov.au/reports/overweight-obesity/overweight-obesity-australia-birth-cohort-analysis/summary.
- 2Blagojevic M, Jinks C, Jeffery A, Jordan KP. Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis. Osteoarthr. Cartil. 2010; 18: 24–33.
- 3Changulani M, Kalairajah Y, Peel T, Field RE. The relationship between obesity and the age at which hip and knee replacement is undertaken. J. Bone Joint Surg. Br. 2008; 90: 360–3.
- 4D'Apuzzo MR, Novicoff WM, Browne JA. The John Insall award: morbid obesity independently impacts complications, mortality, and resource use after TKA. Clin. Orthop. Relat. Res. 2015; 473: 57–63.
- 5George J, Piuzzi NS, Ng M, Sodhi N, Khlopas AA, Mont MA. Association between body mass index and thirty-day complications after Total knee arthroplasty. J. Arthroplast. 2018; 33: 865–71.
- 6Roth A, Khlopas A, George J et al. The effect of body mass index on 30-day complications after revision total hip and knee arthroplasty. J. Arthroplast. 2019; 34: S242–S8.
- 7Werner BC, Evans CL, Carothers JT, Browne JA. Primary Total knee arthroplasty in super-obese patients: dramatically higher postoperative complication rates even compared to revision surgery. J. Arthroplast. 2015; 30: 849–53.
- 8Dowsey MM, Choong PF. Obesity is a major risk factor for prosthetic infection after primary hip arthroplasty. Clin. Orthop. Relat. Res. 2008; 466: 153–8.
- 9Malinzak RA, Ritter MA, Berend ME, Meding JB, Olberding EM, Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J. Arthroplast. 2009; 24: 84–8.
- 10Namba RS, Paxton L, Fithian DC, Stone ML. Obesity and perioperative morbidity in total hip and total knee arthroplasty patients. J. Arthroplast. 2005; 20: 46–50.
- 11Amin AK, Patton JT, Cook RE, Brenkel IJ. Does obesity influence the clinical outcome at five years following total knee replacement for osteoarthritis? J. Bone Joint Surg. Br. 2006; 88: 335–40.
- 12Dowsey MM, Liew D, Stoney JD, Choong PF. The impact of obesity on weight change and outcomes at 12 months in patients undergoing total hip arthroplasty. Med. J. Aust. 2010; 193: 17–21.
- 13Foran JR, Mont MA, Rajadhyaksha AD, Jones LC, Etienne G, Hungerford DS. Total knee arthroplasty in obese patients: a comparison with a matched control group. J. Arthroplast. 2004; 19: 817–24.
- 14Singh V, Yeroushalmi D, Lygrisse KA, Simcox T, Long WJ, Schwarzkopf R. The influence of obesity on achievement of a ‘forgotten joint’ following total knee arthroplasty. Arch. Orthop. Trauma Surg. 2021; 142: 491–9.
- 15Pronk Y, Peters M, Brinkman JM. Is patient satisfaction after total knee arthroplasty predictable using patient characteristics and preoperative patient-reported outcomes? J. Arthroplast. 2021; 36: 2458–65.
- 16Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin. Orthop. Relat. Res. 2010; 468: 57–63.
- 17Brokelman R, van Loon C, van Susante J, van Kampen A, Veth R. Patients are more satisfied than they expected after joint arthroplasty. Acta Orthop. Belg. 2008; 74: 59–63.
- 18Haanstra TM, van den Berg T, Ostelo RW et al. Systematic review: do patient expectations influence treatment outcomes in total knee and total hip arthroplasty? Health Qual. Life Outcomes 2012; 10: 152.
- 19Hamilton DF, Lane JV, Gaston P et al. What determines patient satisfaction with surgery? A prospective cohort study of 4709 patients following total joint replacement. BMJ Open 2013; 3: e002525.
- 20Judge A, Arden NK, Kiran A et al. Interpretation of patient-reported outcomes for hip and knee replacement surgery: identification of thresholds associated with satisfaction with surgery. J. Bone Joint Surg. Br. 2012; 94: 412–8.
- 21Lingard EA, Sledge CB, Learmonth ID, Kinemax OG. Patient expectations regarding total knee arthroplasty: differences among the United States, United Kingdom, and Australia. J. Bone Joint Surg. Am. 2006; 88: 1201–7.
- 22Mannion AF, Kampfen S, Munzinger U, Kramers-de QI. The role of patient expectations in predicting outcome after total knee arthroplasty. Arthritis Res. Ther. 2009; 11: R139.
- 23Vissers MM, de Groot IB, Reijman M, Bussmann JB, Stam HJ, Verhaar JA. Functional capacity and actual daily activity do not contribute to patient satisfaction after total knee arthroplasty. BMC Musculoskelet. Disord. 2010; 11: 121.
- 24Noble PC, Conditt MA, Cook KF, Mathis KB. The John Insall award: patient expectations affect satisfaction with total knee arthroplasty. Clin. Orthop. Relat. Res. 2006; 452: 35–43.
- 25Klem NR, Smith A, O'Sullivan P et al. What influences patient satisfaction after TKA? A qualitative investigation. Clin. Orthop. Relat. Res. 2020; 478: 1850–66.
- 26Scott CE, Bugler KE, Clement ND, MacDonald D, Howie CR, Biant LC. Patient expectations of arthroplasty of the hip and knee. J. Bone Joint Surg. Br. 2012; 94: 974–81.
- 27Hawker GA, Conner-Spady BL, Bohm E et al. Patients' preoperative expectations of total knee arthroplasty and satisfaction with outcomes at one year: A prospective cohort study. Arthritis Rheumatol. 2021; 73: 223–31.
- 28Dunbar MJ, Richardson G, Robertsson O. I can't get no satisfaction after my total knee replacement: rhymes and reasons. Bone Joint J. 2013; 95-B: 148–52.
- 29Ghomrawi HMK, Lee LY, Nwachukwu BU et al. Preoperative expectations associated with postoperative dissatisfaction after total knee arthroplasty: A cohort study. J. Am. Acad. Orthop. Surg. 2020; 28: e145–e50.
- 30Hafkamp FJ, Gosens T, de Vries J, den Oudsten BL. Do dissatisfied patients have unrealistic expectations? A systematic review and best-evidence synthesis in knee and hip arthroplasty patients. EFORT Open Rev. 2020; 5: 226–40.
- 31Sabah SA, Alvand A, Beard DJ, Price AJ. Minimal important changes and differences were estimated for Oxford hip and knee scores following primary and revision arthroplasty. J. Clin. Epidemiol. 2022; 143: 159–68.
- 32Conner-Spady BL, Marshall DA, Bohm E, Dunbar MJ, Noseworthy TW. Comparing the validity and responsiveness of the EQ-5D-5L to the Oxford hip and knee scores and SF-12 in osteoarthritis patients 1 year following total joint replacement. Qual. Life Res. 2018; 27: 1311–22.
- 33Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole MR. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001; 94: 149–58.
- 34Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur. J. Pain 2004; 8: 283–91.
- 35Norman R, Cronin P, Viney R. A pilot discrete choice experiment to explore preferences for EQ-5D-5L health states. Appl. Health Econ. Health Policy 2013; 11: 287–98.
- 36Winiarsky R, Barth P, Lotke P. Total knee arthroplasty in morbidly obese patients. J. Bone Joint Surg. Am. 1998; 80: 1770–4.
- 37Fitzgerald JD, Orav EJ, Lee TH et al. Patient quality of life during the 12 months following joint replacement surgery. Arthritis Rheum. 2004; 51: 100–9.
- 38Si HB, Zeng Y, Shen B et al. The influence of body mass index on the outcomes of primary total knee arthroplasty. Knee Surg. Sports Traumatol. Arthrosc. 2015; 23: 1824–32.
- 39Overgaard A, Lidgren L, Sundberg M, Robertsson O, Annette W-D. Patient-reported 1-year outcome not affected by body mass index in 3,327 total knee arthroplasty patients. Acta Orthop. 2019; 90: 360–5.
- 40Torres-Claramunt R, Hinarejos P, Leal-Blanquet J et al. Does obesity influence on the functional outcomes of a total knee arthroplasty? Obes. Surg. 2016; 26: 2989–94.
- 41Steinhaus ME, Buller LT, Romero JA, Lee YY, Figgie MP, McLawhorn AS. Body mass index classification is independently associated with health-related quality of life after primary total knee arthroplasty: an institutional registry-based study. J. Knee Surg. 2020; 33: 399–409.
- 42Rajgopal V, Bourne RB, Chesworth BM, MacDonald SJ, McCalden RW, Rorabeck CH. The impact of morbid obesity on patient outcomes after total knee arthroplasty. J. Arthroplast. 2008; 23: 795–800.
- 43Collins JE, Donnell-Fink LA, Yang HY et al. Effect of obesity on pain and functional recovery following total knee arthroplasty. J. Bone Joint Surg. Am. 2017; 99: 1812–8.
- 44Parratte S, Pesenti S, Argenson JN. Obesity in orthopedics and trauma surgery. Orthop. Traumatol. Surg. Res. 2014; 100: S91–7.
- 45Bin Abd Razak HR, Chong HC, Tan AH. Obesity does not imply poor outcomes in Asians after total knee arthroplasty. Clin. Orthop. Relat. Res. 2013; 471: 1957–63.
- 46Hamoui N, Kantor S, Vince K, Crookes PF. Long-term outcome of total knee replacement: does obesity matter? Obes. Surg. 2006; 16: 35–8.
- 47Issa K, Pivec R, Kapadia BH et al. Does obesity affect the outcomes of primary total knee arthroplasty? J. Knee Surg. 2013; 26: 89–94.
- 48Martinez-Cano JP, Zamudio-Castilla L, Chica J, Martinez-Arboleda JJ, Sanchez-Vergel A, Martinez-Rondanelli A. Body mass index and knee arthroplasty. J Clin Orthop Trauma. 2020; 11: S711–S6.
- 49McCalden RW, Charron KD, MacDonald SJ, Bourne RB, Naudie DD. Does morbid obesity affect the outcome of total hip replacement?: an analysis of 3290 THRs. J. Bone Joint Surg. Br. 2011; 93: 321–5.
- 50Halawi MJ, Gronbeck C, Savoy L, Cote MP. Effect of morbid obesity on patient-reported outcomes in total joint arthroplasty: a minimum of 1-year follow-up. Arthroplast Today 2019; 5: 493–6.
- 51Braeken AM, Lochhaas-Gerlach JA, Gollish JD, Myles JD, Mackenzie TA. Determinants of 6-12 month postoperative functional status and pain after elective total hip replacement. Int. J. Qual. Health Care 1997; 9: 413–8.
- 52Busato A, Roder C, Herren S, Eggli S. Influence of high BMI on functional outcome after total hip arthroplasty. Obes. Surg. 2008; 18: 595–600.
- 53Davis AM, Wood AM, Keenan AC, Brenkel IJ, Ballantyne JA. Does body mass index affect clinical outcome post-operatively and at five years after primary unilateral total hip replacement performed for osteoarthritis? A multivariate analysis of prospective data. J. Bone Joint Surg. Br. 2011; 93: 1178–82.
- 54Jones CA, Voaklander DC, Johnston DW, Suarez-Almazor ME. The effect of age on pain, function, and quality of life after total hip and knee arthroplasty. Arch. Intern. Med. 2001; 161: 454–60.
- 55Mukka S, Rolfson O, Mohaddes M, Sayed-Noor A. The effect of body mass index class on patient-reported health-related quality of life before and after total hip arthroplasty for osteoarthritis: registry-based cohort study of 64,055 patients. J Bone Joint Surg 2020; 5: e20.00100.
- 56Stickles B, Phillips L, Brox WT, Owens B, Lanzer WL. Defining the relationship between obesity and total joint arthroplasty. Obes. Res. 2001; 9: 219–23.
- 57Fisher DA, Dierckman B, Watts MR, Davis K. Looks good but feels bad: factors that contribute to poor results after total knee arthroplasty. J. Arthroplast. 2007; 22: 39–42.
- 58Lopez-Olivo MA, Landon GC, Siff SJ et al. Psychosocial determinants of outcomes in knee replacement. Ann. Rheum. Dis. 2011; 70: 1775–81.
- 59Zhang L, Lix LM, Ayilara O, Sawatzky R, Bohm ER. The effect of multimorbidity on changes in health-related quality of life following hip and knee arthroplasty. Bone Joint J. 2018; 100-B: 1168–74.
- 60Gandhi R, Davey JR, Mahomed N. Patient expectations predict greater pain relief with joint arthroplasty. J. Arthroplast. 2009; 24: 716–21.
- 61Munn JS, Culliton SE, Bryant DM, MacDonald SJ, Chesworth BM. Can met expectations moderate the relationship between pain/function and satisfaction in total knee arthroplasty? J. Arthroplast. 2021; 36: 1942–6.
- 62Andrew JG, Palan J, Kurup HV, Gibson P, Murray DW, Beard DJ. Obesity in total hip replacement. J. Bone Joint Surg. Br. 2008; 90: 424–9.
- 63Ibrahim T, Hobson S, Beiri A, Esler CN. No influence of body mass index on early outcome following total hip arthroplasty. Int. Orthop. 2005; 29: 359–61.
- 64Katakam A, Florissi IS, Colon Iban YE et al. Class III obesity increases risk of failure to achieve the 1-year hip disability and osteoarthritis outcome score-physical function short form minimal clinically important difference following total hip arthroplasty. J. Arthroplast. 2021; 36: 187–92.
- 65Baker P, Muthumayandi K, Gerrand C, Kleim B, Bettinson K, Deehan D. Influence of body mass index (BMI) on functional improvements at 3 years following total knee replacement: a retrospective cohort study. PLoS One 2013; 8: e59079.
- 66Giesinger JM, Loth FL, MacDonald DJ et al. Patient-reported outcome metrics following total knee arthroplasty are influenced differently by patients' body mass index. Knee Surg. Sports Traumatol. Arthrosc. 2018; 26: 3257–64.
- 67Khatib Y, Badge H, Xuan W, Naylor JM, Harris IA. Patient satisfaction and perception of success after total knee arthroplasty are more strongly associated with patient factors and complications than surgical or anaesthetic factors. Knee Surg. Sports Traumatol. Arthrosc. 2020; 28: 3156–63.
- 68Merle-Vincent F, Couris CM, Schott AM et al. Factors predicting patient satisfaction 2 years after total knee arthroplasty for osteoarthritis. Joint Bone Spine 2011; 78: 383–6.
- 69Canfield M, Savoy L, Cote MP, Halawi MJ. Patient-reported outcome measures in total joint arthroplasty: defining the optimal collection window. Arthroplast Today 2020; 6: 62–7.
- 70Kagan R, Anderson MB, Christensen JC, Peters CL, Gililland JM, Pelt CE. The recovery curve for the patient-reported outcomes measurement information system patient-reported physical function and pain interference computerized adaptive tests after primary total knee arthroplasty. J. Arthroplast. 2018; 33: 2471–4.
- 71van der Wees PJ, Wammes JJ, Akkermans RP et al. Patient-reported health outcomes after total hip and knee surgery in a Dutch university hospital setting: results of twenty years clinical registry. BMC Musculoskelet. Disord. 2017; 18: 97.
- 72Dailiana ZH, Papakostidou I, Varitimidis S et al. Patient-reported quality of life after primary major joint arthroplasty: a prospective comparison of hip and knee arthroplasty. BMC Musculoskelet. Disord. 2015; 16: 366.
- 73Franklin PD, Harrold L, Ayers DC. Incorporating patient-reported outcomes in total joint arthroplasty registries: challenges and opportunities. Clin. Orthop. Relat. Res. 2013; 471: 3482–8.
- 74Chenok K, Teleki S, SooHoo NF, Huddleston J 3rd, Bozic KJ. Collecting Patient-Reported Outcomes: Lessons From the California Joint Replacement Registry, Vol. 3. Washington DC: EGEMS, 2015; 1196.
