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Does Body Mass Index Affect The Early Outcome of Primary Total Hip Arthroplasty?

Matthew Moran, MRCSEd, P. Walmsley, MRCSEd,A. Gray, MRCS, and I.J. Brenkel, FRCS

Abstract:

There is little evidence describing the influence of body mass index on theoutcome of total hip arthroplasty (THA). Eight hundred patients undergoing primarycemented THA were followed for a minimum of 18 months. The Harris Hip Score(HHS) and Short Form 36 were recorded preoperatively and at 6 and 18 monthspostoperatively. In addition, other significant events were noted, namely death,dislocation, reoperation, superficial and deep infection, and blood loss. Multipleregression analysis was performed to identify whether body mass index (BMI) wasan independently significant predictor of the outcome of THA. No relationship wasseen between the BMI of an individual and the development of any of thecomplications noted. The HHS was seen to increase dramatically postoperatively inall patients. Body mass index did predict for a lower HHS at 6 and 18 months. Thiseffect was small when compared with the overall improvements in these scores.There was no influence on the Short Form 36 component scores. On the basis of thisstudy, wecan find nojustification forwithholding THAsolely onthe grounds ofBMI.

Key words:

body mass index, total hip arthroplasty, Harris Hip Score.

Total hip arthroplasty (THA) provides long-lastingimprovement in quality of life and reduction inpain for patients with disabling arthritis. However,there are groups of patients that have been shownto have outcomes that are poorer than the generalpopulation. A poorer outcome may be affected bythe underlying diagnosis, for example, femoralneck fracture[1];by the choice of implant, for example, the Capital THA[2];or by the surgeon, for example, infrequently performed THA[3].There are concerns that an increasing body massindex (BMI) negatively impacts on the outcomeof THA, and surgeons may decline to operateon the obese for fear of the complications thatmay follow. Possible areas of increased complica-tionsinclude increased length ofoperative time [4,5], venous thromboem bolism[6], superficial anddeep wound infection[7], increased blood loss [8,9], and aseptic loosening due to increasedloading through the THA.Despite the theoretical increased rate of compli-cations, there is evidence to show that the symp-tomaticrelief afterTHA isaseffective intheobeseasinthinnerpatients[10,11].In2000,theUKNationalAudit Office criticized orthopedic surgeons for theuse of

varying criteria for weight above which theymay not operate

[12]. It is important that decisionsaboutthesuitabilityofpatientsforsurgeryaremadeon good evidence. We set out to examine the earlycomplication rate in obese patients after THA.

The Journal of Arthroplasty Vol. 20 No. 7 2005

866

From the Department of Orthopaedic Surgery, Queen Margaret Hospital, Dunfermline, Fife, UK.

Submitted November 18, 2003; accepted February 3, 2005.No benefits or funds were received in support of the study.Reprint requests: Matthew Moran, MRCSEd, 19 PlewlandsGardens, EH10 5JS Edinburgh, UK.

Methods

Patients

Eight hundred consecutive patients undergoingCharnley primary THA (De Puy International,Leeds, UK) were investigated prospectively. Thepatients were under the care of 6 consultantorthopedic surgeons at a single hospital. The jointarthroplasties were carried out between January1998 and November 2000. A standard anterolateralapproach to the hip was used by all surgeons. Datafrom the patients were collected by a specialistnurse and stored on a local database.The following events were recorded: length ofstay in the hospital, death, dislocation, reoperation,superficial and deep wound infection, blood loss,and transfusion requirement. Superficial woundinfection was diagnosed in the presence of dis-charge from the surgical wound or spreadingcellulitis and a positive microbiological culture ofa microorganism known to be implicated in causingwound infection. Deep infection was suspected onclinical and radiological grounds but only diag-nosed after the growth of putative microorganismsfrom specimens taken at reoperation. Blood losswas calculated from perioperative losses (suctionand swabs) plus postoperative drainage.Concomitant medical problems were recordedunder the headings: smoker, cancer, atherosclero-sis, cardiac, diabetes mellitus, osteoporosis, andthromboembolism.

Outcome Measures

The Harris Hip Score (HHS) and Short Form 36(SF-36)were the primary outcome measures used[13,14]. The HHS combines scores for pain, func-tion, activities, absence of deformity, and range ofmotion to produce an overall score out of 100(0, bad; 100, good). The score is mostly determined by feedback from the patient and weighted stronglytoward pain and function. It has been shown to be a reliable indicator of patient function and pain before and after THA[15].The SF-36 is a widely used measure of patient health that is not specificto one disease. It is agoodmeasure of patientsymptoms after THA[16]. Both scores werecompleted 7 days preoperatively as well as 6 and18 months postoperatively.Body mass index was taken as a marker ofobesity. It is calculated from the weight (kilograms)divided by the square of the height (meters). TheBMI is widely recognized as a tool for the simplecalculation of obesity. It corrects the weight of thepatient for their height. A score is generated with20 to 24.9 kg/m

reflecting ideal weight, 25 to29.9 kg/m

reflecting overweight, 30 to 39.9 kg/m

reflecting obesity, and 40 kg/m

or greater reflect-ing morbid obesity.

Statistics

The SPSSv9.0 (SPSS Inc, Chicago, Ill) computerpackage was used to analyze results.The paired Student

test was used to detectchanges in the HHS before and after surgery.Univariate analysis was performed using

tests,2-sample

tests, or Pearson’s correlation coefficientto identify significant predictors of the measuredoutcomes. The predictors were operating surgeon,age, sex, side of surgery, length of stay in hospital,concomitant medical problems (see above), bloodloss, transfused units of blood, and preoperativeHHS. The outcomes were reoperation, death,dislocation, deep and superficial infection, andHHS. Once possibly significant predictors of out-come had been identified by this method, stepwisemultiple regression analysis was carried out toidentify any predictors that would independentlyalter outcome. Multiple logistic regression wasperformed for binary outcomes (eg, death) andmultiple regression linear analysis for continuousvariables (eg, HHS).

Results

Eight hundred total hip arthroplasties werecarried out in 759 patients. Sixty-one percent werefemale and 39% male. Four hundred fifty-nineTHAs were left sided. The mean age was 68 years.Of the 800 THA episodes, all completed a preoper-ative HHS and SF-36. Seven hundred seventy-fourcompletedanHHS/SF-36at6monthsand687com-pleted the scores at 18 months. The mean BMI was

050100150200250300350<20 20-24.9 25-29.9 30-39.9 40+

Body Mass Index

N u m b e r o f p a t i e n t s

Fig. 1.

Distribution of patients by obesity category.

Does Body Mass Index Affect The Early Outcome of Primary THA?

Moran et al

867

27.8 kg/m

(range, 17-49) with a standard devia-tion of 5 (Fig. 1). There was no difference in the BMI of patients defaulting to follow-up and thosewho completed follow-up (

= .32). On average,0.7 units of blood were transfused and mean bloodloss was 537 mL (SD, 296 mL). The mean length ofstay was 10 days.Thirty-three patients had died by the 18-monthfollow-up (39 hips). There had been 13 dislocations(at an average of 15 weeks). Fifteen patientsunderwent a further operation (not includingreduction of a dislocated joint). Three revisionoperations, 11 debridements, and 1 posterior lipaugmentwerecarriedoutwithinthefirst18months.Seven deep infections and 56 superficial woundinfections had occurred by 18 months.The mean preoperative HHS was 42. This im-proved to 81 at 6 months and 85 at 18 monthspostoperatively. There was a significant improve-ment in the HHS scores at 6 and 18 months whencompared with the preoperative score (

.0001).Univariate analysis suggested that BMI mightpredict for increased rates of superficial infectionand a lower HHS at 6 and 18 months postopera-tively (all

.05). However, once multiple logisticregression was carried out, BMI was not found to be a significant independent predictor of superficialwound infection.When multiple regression analysis was per-formed for the HHS at 6 and 18 months, takinginto account other significant predictors, BMI wasstill found to be significant (

= .02 at 6 months and

.001 at 18 months). To calculate the individualeffect a change in BMI might have on HHS, themultiple regression coefficient

was noted. At6 months,

.25 (95% confidence intervals[CIs],

.05 to

.45), and at 18 months,

.35(95% CIs,

.15 to

.55). That is, for every 1 pointincrease in BMI, the HHS dropped on average by0.25 or 0.35. The other predictors with a significantindividual influence on thepostoperative HHS werelength of stay, previous thromboembolism or coro-nary heart disease, drop in hemoglobin at 24 hours,and preoperative HHS. By far, the most significantof these is the preoperative HHS (seeFig. 2).Body mass index was not a significant predictorfor any of the SF-36 component scores.

Discussion

The HHS improved considerably after surgery.The hip score is weighted toward the patient’sassessment of pain, function, and activity (91 of100 points), with lesser emphasis on surgeon-determined measures such as range of motionand absence of deformity (9 of 100). Ultimately,the patients’ view on the outcome of surgery isprobably the most important, and the HHS is a goodmeasure of patient symptoms.Body mass index independently predicted fora lower HHS at 6 and 18 months. However, itsindividual effect, whereas significant statistically,was small. If we take a change in BMI of 20 points(the difference between being underweight andmorbidly obese), we estimate that it will onlyproduce on average a lowering in the HHS of 5.0 at6 months and 7.0 at 18 months. These changes aresmall given that the mean improvement in the HHSat 18 months is 43. None of the 9 component scoresof the SF-36 were predicted by BMI.We saw no relationship between BMI and earlyfailure of THA. Although the obese may putincreased loads through their joint arthroplasty,there is evidence that the more obese a patient, theless active they are. Hence, the increased weight is balanced by decreased cycles of loading[17].In a paper comparing 41 obese and 125 nonobesepatients, Soballe et al[9]noted increased blood lossin the obese group. In a series of 80 patients,Bowditch and Vilar[8]also noted increased bloodloss in obese patients when compared to thoseof ideal weight. Multiple regression analysis is asophisticated tool that allows for the correction ofother variables in assessing the individual influenceof BMI. Even with the large numbers in our study,onceotherfactorssuchascomorbidityaretakenintoaccount, we did not find that BMI per se increasedmeasured blood loss or transfusion requirement.

051015202530

BaselineHHSLength stay Comorbidity Drop Hb BMI

% v a r i a n c e e x p l a i n e d

HHS 6HHS 18

Fig. 2.

Therelative contributions (percentage ofvarianceexplained) of predictors to the HHS at 6 and 18 months.Comorbidity indicates coronary and thromboembolism;Hb, hemoglobin; HHS 6, Harris Hip Score at 6 months;HHS 18, Harris Hip Score at 18 months.

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The Journal of Arthroplasty Vol. 20 No. 7 October 2005

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