In this episode of PodMD, A/Prof Sam Adie, Orthopaedic Surgeon will chat about helping your patient with relevant weight loss before joint replacement surgery. He will discuss how to help them through the journey, who is more predisposed to this and how to make exercise accessible to someone with painful joints already
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Dr Sean Mackay : Today I’d like to welcome back to the PodMd studio A/Prof Sam Adie
Associate Professor Sam Adie specialises in surgery of the hip and knee, including total hip and knee replacement, and arthroscopic (keyhole) knee surgery.
Today, we’ll be discussing weight loss and joint replacement
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
Can you give us an overview on the link between weight loss and joint replacement?
So, we are seeing really a massive increase in people having knee replacements because of the epidemic of obesity and weight gain. So, if you look at the number of total knee replacements that are being done in Australia every year first of all, it is increasing year on year. But secondly, we are saying that about two thirds of those total knee replacements are in patients that are obese. And if you include patients that are also overweight, when are thinking about three quarters of all total knee replacements being either overweight or obese. So, it is really a big problem. And this is also an issue beyond the actual arthritic joint. So, when you think about all of the problems that obesity causes for our society in terms of chronic disease cardiovascular disease, diabetes, uh, even the risk of cancer, then obesity does become really a huge public health issue.
Who is the right candidate for losing weight before a joint replacement?
So, if you look at the evidence, people with obesity who undergo a total knee replacement really do have an increased risk of pretty much all potential complications that can occur after a total knee replacement. So think about even really rare, but devastating things like wound infection and deep infection around the prosthesis loosening of the prosthesis interoperative complications like fracture on your vascular injury stiffness after the surgery, functional outcomes have also been shown to be effected. So, that evidence has been quite controversial in the past, but I think on the balance of it you have to admit that patients with obesity are at a higher risk of getting these complications. And that is not just a significant thing. When you think about the number of these total knee replacements that have been done on patients that are obese but also that how much, this is sort of a burden on our society when you’re doing surgery on patients that can potentially be optimized and then have a reduced sort of complication and risk profile, uh, prior to their surgery. So, and really answering the question, I would suggest that any candidate who is obese and overweight should attempt to lose weight before having their joint replacement. And we do know that even a small amount of weight loss only about 5% does affect the outcomes after surgery
Is there anyone that would be more predisposed to joint damage? How would this affect them in their weight loss?
So, that’s a really important question, Sean, because we get that a lot. So, patients come to us and they’ve got really bad arthritis and they’ve got a painful joint and they complained that they can’t really do any exercise because of their painful joint. So, I’m not discounting that that is a really big issue. So if patients can’t do any exercise because of how painful their arthritis is then clearly that’s that’s going to be a problem for them participating in any weight loss programs, but I would point out two things here. First of all weight loss need not depend on them having an exercise program. And we do know that weight loss is really predominantly about patient’s dietary intake. So really it’s all about improving their diet reducing their caloric intake. And also there are some new diets available now that have been, that had, do have some evidence that that they can improve arthritic symptoms.
So, things like the low inflammatory diet or the so-called Mediterranean diet there, we’re actually doing a study on at the moment. So, there is some evidence that particular diets can improve joint symptoms, but also result in patients losing weight. Other diets are available. So for example, the very low calorie diet, that’s where people substitute their meals for example, very low calorie, supplements like shakes, et cetera. So, there are things available under the, I would suggest that they need to be under the guidance of a professional, such as dietician or a GP, if they take an interest in that, or they can be referred to a metabolic or obesity clinic. And these are available in, well, at least in Sydney where I’m based, there are, clinics available that patients can be referred to in order to manage their obesity beforehand.
There are also exercises that patients can do that are low impact, so they don’t really involve impacting and, and really loading the joint. So, think of things like swimming or, riding a stationary bike or doing an elliptical machine, for example, that tend to be a little bit more low impact on the joint and better tolerated for the patient. And then finally, I can’t avoid the question of obesity surgery. So, bariatric surgery is also becoming more and more common. That is an unanswered question at the moment about whether patients with arthritis who are candidates for a total knee replacement should be referred to surgery first because obviously the bariatric surgery also has its own risk profile and complications that can occur after it. We do know that bariatric surgery is extremely effective in terms of people losing weight and maintaining the weight loss for up to 10 years after the surgery. But what we don’t know at the moment is whether referral to that, uh, bariatric surgery is going to improve their overall risk profile and their outcomes after a joint replacement. I would suggest though that people with extreme obesity, so think patients with a BMI greater than 40, for example, those are the patients in a very high risk category that really should be offered. Um, you know, some sort of extreme weight loss measure before they consider any joint replacement surgery
What can a GP aide in recognising an applicable patient? What are the warning signs or red flags that weight loss may be needed before surgery?
So, I think any patient who is obese and overweight should at least attempt to lose weight. And I’m saying this because it’s I’m really being a little bit controversial here because a lot of my colleagues would disagree with me. They would suggest that patients that are already obese, um, have a very low chance of actually losing significant amounts of weight and really we’re fighting a losing battle here. The problem I have with that is that we haven’t really attempted to do anything that may be seen as effective. And certainly we haven’t generated enough evidence to show what programs may be effective for patients losing weight in the studies that we have done, um, where patients do lose weight. We have seen that those patients do have improved symptoms of their arthritis. So some of those patients actually take themselves off the waiting list for having a joint replacement, for example, and in the most recent study that we did, it was about 5% of patients that actually, you know, didn’t want the surgery at all after they lost a significant amount of weight.
Also, we think that it improves their risk profile after they have the surgery. So, as I mentioned earlier, obesity is a major public health issue. It’s a major issue for patients having the surgery in terms of increasing their risks and complications after the surgery. So we think that improving their obesity before the surgery does have a link with their complications after surgery. In other words, it’s going to improve their outcome. Now we’re trying to prove that with the studies that we’re doing at the moment, we don’t have a clear link at the moment, but it is a very, you know logical thing to think about that patients you know, reducing their weight prior to surgery are going to have a lower complication risk after a total knee replacement
How then, can GPs help in the whole process of losing weight for joint replacement?
So, I think the GPS is really a key member of the health team that centralizes all of the multidisciplinary care that’s going to be needed for patients to lose weight. So, it really is a challenge as you know, for patients to lose weight generally, but in particular, um, in the context of arthritis so that’s, they’re gonna need as much help as possible. So I think the GP is critical in terms of referral to this multidisciplinary team. I would encourage patients to be referred to, for example, a dietician, a physiotherapist, or an exercise physiologist as well as an orthopedic surgeon who can sort of counsel them about whether they’re ready for the surgery and what their risk profile might be, uh perioperatively and what to expect from the surgery, if they continue to maintain their current weight. Now in many places around Australia, there are multidisciplinary teams that can help optimize these patients prior to their surgery. And we’re lucky to have that in our own practice where we have access to, you know, physios and sports physicians, as well as orthopedic surgeons that can help, uh, manage these patients through their journey.
Is there a specific type of exercise that works for people that have obviously damaged joints but need to lose weight?
So this is really, really hard. Sean, so, as we sort of touched upon earlier patients commonly complain that they can’t exercise because of their painful arthritic joint. Now I always remind patients when they tell me that, that it is mostly about their eating and their diet. And, and I always remind them that it is really, really hard. So anyone who’s ever attempted to lose weight knows how much of a challenge there is. And I sort of reassure them and sort of you know, empathise with them on that level, but also at the same time, offer them a lot of help. So it’s really important that they see as many professionals as possible. So, think dieticians that can invite that can advise them on their caloric intake and what sort of food they should be choosing and their overall meal plan and also a physiotherapist or an exercise physiologist that can sort of tailor an exercise program that is going to be less impactful on their diseased joint, but also allow them to maintain enough sort of cardiovascular activity in order for them to actually benefit from, for weight loss.
I would suggest that a low impact exercise is going to work best. So, think things like swimming or riding a stationary bike, for example or upper body exercises using weights. So, there’s always things that they can they can do that can spare their arthritic joint. And the final thing I would say is it’s always important to remember that exercise itself is a really important treatment for patients with arthritis. So we’re not trying to avoid exercising that joint or together. Because we do know that, um, you know, established, uh, physiotherapy programs have a lot of evidence for improving patient’s symptoms, even when they have quite advanced arthritis, it’ll never reverse their arthritis, but it will certainly improve the symptoms that they have from arthritis in terms of pain and stiffness, for example testing
When should a GP refer?
So I think the GP, as I said, is really the key figure coordinating the patient’s care through this often quite difficult journey. I would suggest that a GP should refer early. I mean, clearly the patient has presented with at least two chronic problems, both of which are quite difficult to manage so obesity and, you know, arthritis. So, I would suggest that the, that the GP really needs as much help as possible. And that is going to come from both allied health staff dieticians, physiotherapists, exercise physiologists as well as specialists like sports and exercise physicians and orthopedic surgeons, if a patient comes to a GP and they are obese as in a BMI over 30, uh, and they have symptoms of arthritis, uh, that have shown up on a bearing x-ray in terms of joint space loss and cartilage loss, then I would suggest that the GP should refer early to a multidisciplinary team
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on weight loss and joint replacement.
So, Sean, I think the first message is that obesity is a massive public health problem, is its association with all sorts of chronic health conditions, but also for patients with knee osteoarthritis. And we are seeing really rapid increase in patients having total knee replacements commonly as a result of their overweight and obesity. Secondly, we do know that obesity does increase, patient’s complications after having a total knee replacement. So really makes sense for patients to try and lose weight before their surgery, even you know, as little as 5% body mass loss will improveboth their symptoms preoperatively, and also potentially their outcomes after a total knee replacement. And thirdly, there’s a lot of help out there in terms of what we can do to, uh, to help these patients on their journey. So, I think a multidisciplinary team is really critical, and also that we are also generating quite a lot of evidence on this area in terms of what the optimum weight loss approaches are for these patients
Thanks again for your time and the insight’s you’ve provided.
Thanks very much for having me, Sean.