I have had many patients see me with the same story, they have been told they are “too fat for a joint replacement”.
Once a patient has developed arthritis in the hip they generally have pain and discomfort. Overweight patients put even more stress on an arthritic hip and subsequently may have more rapid progression of arthritis, and worse symptoms. It is therefore unsurprising that patients needing hip replacement surgery often have higher BMI or body weight.
It is also common that patients may have too high a BMI to safely have a total hip replacement. From a patients perspective they may feel they have been told ‘you are too fat for a hip replacement’, but I would hope from a medical professionals perspective a careful conversation had been hadabout the risks and benefits, and why a decision for surgery would be unsafe.
Either way a patient may feel deflated in this situation, as losing weight with arthritis is a very challenging thing to do.
↑ Before and after total hip replacement for bone on bone arthritis in a high BMI patient who chose the MAKO robotic system to accurately position the hip replacement in this challenging setting.
The challenge of being overweight with arthritis
As a hip surgeon I strongly feel that risks of surgery should be minimised wherever possible, in this situation this means a BMI for 35 – 40 being the upper limit for performing a total hip replacement. The exact figure would depend on patient factors such as fat distribution, and also other risk factors such as diabetes.
High BMI patients have higher complications from hip replacement surgery including but not limited to dislocation, infection, and risk to life. These are not trivial complications and can leave a patient worse off than no surgery at all. I think it is important to make a patient aware of the seriousness of some of the complications so that they understand the decision making.
My approach to managing overweight patients with arthritis
My personal approach when I see a patient whom I feel is too high risk for a hip replacement due to obesity is to discuss the decision making with the patient, discuss alternatives, make a plan for surgical optimisation and offer some ‘light at the end of the tunnel’.
Alternatives to hip replacement may include pain killers, activity modification, and joint injections. Although these are not long term cures, they may allow a patient to lose weight and become fit for surgical treatment.
A team approach is often needed
Surgical optimisation is often a team approach as weight loss with arthritis is so challenging. I work with doctors who have a specialist interest in weight loss and offer treatments that were not available only a few years ago. Working as a team approach with a ‘target weight’ for surgery can be very motivating for the patient and increase the chance of getting the best outcome.
If I see a patient who has a BMI too high for hip replacement I try to ensure I achieve the above in my clinic consultation, and leave the patient with a clear plan of what needs to be done, a target weight for surgery, and what help is available, including home care support.
Light at the end of the tunnel
Because of the viscous cycle arthritis can take when complicated by obesity, patients often feel trapped. Losing weight when mobility is limited is challenging and patients may feel they will never get to a safe level for surgery. This is compounded even further with long waiting lists of up to a year, a patient may feel what is the point!
A big advantage to private healthcare is that patients can choose when to have their treatment. In this setting a patient with hip or knee arthritis can plan a course of weight loss, with the help of a weight loss expert with access to the latest treatments, and time surgery with Mr Samir Ali Salih at the most appropriate time. Many patients have found this approach empowering, and made the weight loss easier than an open ended follow up appointment followed by a one year wait for surgery.
Summary
Obesity is a growing challenge for hip and knee replacement specialists. My approach is patient centered, working with the patient and other specialists to offer the best and safest treatment at the most appropriate time.
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with hip arthritis
Mr Samir Ali Salih
I am a consultant hip and knee surgeon specialising in joint replacements for arthritis using the Stryker MAKO robotic system
This article was written with human intelligence