Tag Archives: TKR

Resources for Fat People Looking for Total Joint Replacement Surgery

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stylized picture of an x-ray in dark blue, with one hip and both knees showing red for pain and inflammation

Debbie says:

A fat person who needs a total joint replacement of their hips and/or their knees can run into an almost impenetrable wall of rejection. Many if not most doctors who perform these surgeries believe the common wisdom that outcomes of these surgeries are affected by the patient’s body mass index (BMI) to the point where many of them simply turn patients away out of hand.

(TL;DR: if you are looking for medical evidence to share with potential surgeons on why they might be wrong, I’ve collected some here and it’s available for you to use. It’s also available for you to add to, so it can be more useful to the next person. Just leave comments with links, and I’ll incorporate the new information. All details and links to the studies listed below are available at the link. Pointers to surgeons who are open to working with fat people also very welcome.)

To begin with, BMI is arrant nonsense; all it is is the ratio of your weight to the square of your height. I wrote about it here in 2007 and nothing about its history (invented by a statistician with no medical training), its uselessness, or its general acceptance by the medical profession has changed in 17 years. I call it “braindead, meaningless, insidious.”

But here we are, being forced to deal with it as if it was real.

I’ve known about the problem with obtaining joint replacement surgery for a long time, but recently a close friend of mine has been going through it, and it made me really angry. It’s especially frustrating because she is very close to the same weight she was in 2017 when she had a successful replacement on the other knee, and now the surgeon who did that one, and several other surgeons, have turned her away without a word of compassion or empathy. “Lose weight and come back,” they say, often that bluntly.

So I decided to do some research. And sure, there’s a lot of research that says BMI increases risk of surgical complications, particularly infection immediately after surgery. But there’s also substantial evidence that this is not necessarily true–my personal guess is that many of the studies that show additional risk are flawed by an implicit bias against doing anything medical to help a fat person until/unless they lose weight.

Some examples from the research linked above:

In a study of 2,040 patients, published in the Journal of Bone and Joint Surgery, July 19, 2017:

 A greater obesity level was associated with more pain at baseline but greater postoperative pain relief, so the average postoperative pain scores did not differ significantly according to BMI status. Patients undergoing TKR had an average age of 69 years; 61% were women, 93% were white, and 25% were severely or morbidly obese. A greater obesity level was associated with a lower PCS score at baseline and 6 months. The postoperative gain in PCS score did not differ by BMI level. A greater obesity level was associated with worse pain at baseline but greater pain relief at 6 months, so the average pain scores at 6 month were similar across the BMI levels.”

In a comprehensive literature review, plus interviews with leading surgeons, published in Arthroplast Today in October 2022:

Importantly, as obese patients have been demonstrated to have equal or greater gains in functional outcomes and quality of life metrics, it is important for obese patients to have access to TJA.

This paper is especially interesting, as it breaks down the factors a surgeon can/should consider in making this decision, taking the conversation away from the rigidity of BMI into a serious examination of risks.

Because so much of the conventional wisdom is some 2020s version of “just lose weight and come back,” I tried to put my finger on truly good studies about the difficulty of losing weight; however, the amount of noise about this, even in serious medical papers, made it almost impossible to evaluate. So the document above closes with information from a careful examination of factors that keep people from losing weight, published in the Journal of Health, Population, and Nutrition, March 2, 2024. The authors identify five major categories of complicating factors preventing weight loss (biological, medical, interventional, lifestyle, and environmental), each with 3-6 subcategories. So it might encourage a doctor to think in a more nuanced way.

Oh, and my friend? She found a fairly reasonable surgeon (or at least his physician’s assistant seems reasonable) who treated her like a human being and paid attention to who she actually is. They still want her to lose weight before scheduling the surgery, but it seems like they have some flexibility in their approach and she feels reasonably comfortable working with them. And she’s waiting a few months — in pain — to see if she can meet their criteria.

Me, I think the whole thing is bullshit and anyone who is in severe pain and physical limitation from needing joint replacement should have the risks explained, and get to make a choice. And the surgeons should be interested in long-term outcomes rather than immediate risks. Oh, and we should have a decent humane health-care system in the United States while we’re at it.

Please use the resource linked above if it can help you. Share it widely so we can make it better. And let me know how useful it is or isn’t.

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