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Obesity Surgery (2018) 28:1395–1401

https://doi.org/10.1007/s11695-017-3034-6

ORIGINAL CONTRIBUTIONS

Bariatric Surgery and Time to Total Joint Arthroplasty: Does It Affect


Readmission and Complication Rates?
Ran Schwarzkopf 1 & Jessica A. Lavery 2 & Jessica Hooper 1 & Manish Parikh 3 & Heather T. Gold 1,4

Published online: 22 November 2017


# Springer Science+Business Media, LLC, part of Springer Nature 2017

Abstract
Background Bariatric surgery is frequently recommended prior to total joint arthroplasty (TJA) for morbidly obese patients with
end-stage arthropathy. Current published data on the efficacy of bariatric surgery for preoperative medical optimization has
yielded mixed results, and the effect of time from bariatric surgery to TJA on the preoperative risk profile is not well defined. Our
study evaluated the effect of time from bariatric surgery to TJA on 90-day complication and readmission rates.
Methods We utilized the Healthcare Cost and Utilization Project (HCUP) California State Inpatient Database (SID) to identify
patients who underwent TJA following bariatric surgery between 2007 and 2011. Primary endpoints were 90-day complication
rates and all-cause 90-day readmission rates following TJA.
Results We identified 330 cases of bariatric surgery followed by total hip arthroplasty (THA) and 1017 cases followed by total
knee arthroplasty (TKA). There were no significant demographic differences among patients who underwent TJA greater than or
less than 6 months after bariatric surgery. Patients undergoing THA more than 6 months after bariatric surgery were significantly
less likely to be readmitted within 90 days for any cause. There was no association between time from bariatric surgery to THA or
TKA and 90-day complications.
Discussion Delaying THA at least 6 months after bariatric surgery may help reduce the rate of 90-day readmissions in this high-
risk patient population. Arthroplasty surgeons recommending bariatric surgery as preoperative risk modification should consider
the patient’s overall nutritional status, medical comorbidities, and overall response to surgery prior to booking for TJA.

Keywords Total joint arthroplasty . Medical optimization . Bariatric surgery . Obesity . Readmission rate . Perioperative
complication rate

Background
Investigation performed at NYU Langone Medical Center in New York,
New York. The prevalence of obesity in adults in the USA has increased
This study was determined to be exempt from review by the institutional
review board.
by 4.9% over the past decade [1, 2]. Obesity contributes to
many chronic medical conditions such as obstructive sleep
* Jessica Hooper apnea, hypertension, hyperlipidemia, diabetes mellitus, and
jessica.hooper@nyumc.org cardiovascular disease [3]. In addition to the increased preva-
1 lence of medical comorbidities in the obese population, these
Department of Orthopedic Surgery, New York University Hospital
for Joint Diseases, 301 E 17th Street, Suite 1402, New patients are also more likely to have metabolic derangements
York, NY 10003, USA and have a higher prevalence of malnourishment compared to
2
Department of Biostatistics, New York University Langone Medical non-obese patients [3].
Center, 550 First Avenue, New York, NY 10016, USA Obesity has also been identified as a risk factor for the
3
Department of Surgery, New York University Langone Medical development of osteoarthritis; increased loads at the hip, and
Center, 550 First Avenue, New York, NY 10016, USA especially at the knee joints, during activities of daily living
4
Department of Population Health, New York University Langone are directly related to increased weight [4, 5]. Obese patients
Medical Center, 550 First Avenue, New York, NY 10016, USA consequently develop end-stage arthropathy more quickly
1396 OBES SURG (2018) 28:1395–1401

than their non-obese peers, and are often younger with more first TJA was selected. Patients who underwent a TJA prior to
medical comorbidities when they are considered for total joint bariatric surgery were excluded (n = 853). To confirm that no
arthroplasty (TJA). Due to the increased technical difficulty of TJA occurred in the year prior to bariatric surgery, we allowed
the operation, malnourished status, and overall poorer health, for a 1-year lookback from bariatric surgery discharge to eval-
obesity is associated with higher complication rates and uate whether TJA occurred, with observation starting in 2006
readmissions following TJA [6, 7]. A body mass index for the 2007 bariatric surgery patients. We excluded patients
(BMI) > 40 kg/m2 has been observed as a threshold at which with more than one bariatric surgery between 2006 and 2011
complications and revision rates increase among TJA patients and patients who underwent TJA for fracture, such as femoral
[8]. The super obese (BMI > 50 kg/m2) patient population has neck fractures. Our final sample included 1347 patients.
been reported to have an even higher risk for perioperative The primary outcomes were 90-day complications and all-
complications [9]. cause 90-day readmission following the TJA. A complication
Bariatric surgery is often recommended prior to TJA for was assessed at the TJA surgical admission and at any read-
morbidly obese patients with end-stage arthropathy. Bariatric mission within 90 days, and included one or more of the
procedures have proven to be a more effective means of following based on ICD-9-CM codes (Table 1): pulmonary
weight loss than nonsurgical interventions in morbidly obese embolism, deep vein thrombosis, acute myocardial infarction,
patients [10], and can help induce partial or complete remis-
sion of obesity-related comorbidities such as type 2 diabetes Table 1 Characteristics of patients undergoing bariatric surgery
mellitus, hypertension, and dyslipidemia [10]. Previous stud- followed by total joint arthroplasty in California (n = 1347), 2007–2011
ies have examined the effect of bariatric surgery prior to TJA Characteristics Total hip arthroplasty Total knee arthroplasty
on perioperative complications and postoperative outcomes, (n = 330) (n = 1017)
but the results remain inconclusive [11–15]. n (%) n (%)
It is not clear from the published evidence how time from
90-day complications
bariatric surgery to TJA surgery affects the TJA risk profile of
an obese patient. We sought to evaluate how the time (months) No 181 (54.8) 687 (67.6)
from bariatric surgery to TJA surgery affected the rate of peri- Yes 149 (45.2) 330 (32.4)
operative TJA complications and readmissions. We hypothe- 90-day all-cause readmission
sized that increasing the time between bariatric surgery to TJA No readmissions 256 (77.6) 842 (82.8)
surgery would allow patients to lose weight and adjust to the Readmission 74 (22.4) 175 (17.2)
metabolic changes that occur after bariatric surgery, leading to Months between bariatric surgery and TJA
lower complication and readmission rates following TJA. 0–6 months 61 (18.5) 98 (9.6)
7–12 months 85 (25.8) 200 (19.7)
13–18 months 53 (16.1) 197 (19.4)
Methods 19–24 months 43 (13.0) 144 (14.2)
> 24 months 88 (26.7) 378 (37.2)
Data Source Age (years; at bariatric surgery)
< 50 years 85 (25.8) 185 (18.2)
We utilized the Healthcare Cost and Utilization Project 50–59 years 153 (46.4) 478 (47.0)
(HCUP) California State Inpatient Database (SID) to identify 60–69 years 80 (24.2) 315 (31.0)
patients that underwent total joint arthroplasty (TJA) follow- 70+ years 12 (3.6) 39 (3.8)
ing bariatric surgery between 2007 and 2011. The HCUP SID Sex
is a population-based dataset encompassing all hospital dis- Male 101 (30.6) 240 (23.6)
charge records from the state of California. ICD-9-CM diag- Female 229 (69.4) 777 (76.4)
nosis and procedure codes were used to identify bariatric sur- Race
gery, total hip arthroplasty (THA), total knee arthroplasty White 279 (84.5) 836 (82.2)
(TKA), and select complications following THA/TKA Black 28 (8.5) 89 (8.8)
(Table 3 in Appendix). These data are de-identified and are Other/unknown 23 (7.0) 92 (9.0)
exempt from IRB review. Ethnicity
Non-Hispanic 300 (90.9) 881 (86.6)
Cohort Selection Hispanic 30 (9.1) 136 (13.4)
Insurance
Patients undergoing bariatric surgery followed by a total joint All other insurance 309 (93.6) 967 (95.1)
replacement (THA or TKA) were identified. If a patient had Ever Medicaid 21 (6.4) 50 (4.9)
more than one TJA following bariatric surgery, then only the
OBES SURG (2018) 28:1395–1401 1397

respiratory failure, cerebrovascular event, urinary tract infec- CI 1.12, 2.17) cohorts. Age, race, ethnicity, and insurance
tion, blood transfusion, cardiac complications, peripheral vas- were not significantly associated with likelihood of a compli-
cular disease, respiratory complications, gastrointestinal com- cation at 90 days for either surgery.
plications, gastrointestinal complications, pneumonia, acute
renal failure, acute cholecystitis, central nervous system prob- 90-Day Readmission
lems, hematoma/seroma, wound dehiscence, postoperative in-
fection, or postoperative anemia. Patients undergoing THA more than 6 months after bariatric
surgery were significantly less likely to have a 90-day read-
Statistical Methods mission for any cause compared to patients undergoing THA
within 6 months after bariatric surgery. No associations were
Multivariable logistic regression models were applied to com- found between age, sex, race, ethnicity or insurance status,
pare the likelihood of a complication or readmission following and readmission after THA. Among TKA patients, there was
TJA for varying time periods between bariatric surgery and no association found between time between surgeries and re-
TJA. THA and TKA patients were assessed separately. Time admission. Age, sex, race and insurance were also not associ-
between bariatric surgery and TJA was calculated in months, ated with readmission following TKA. However, non-
and grouped into categories of 0–6 months, 7–12 months, 13– Hispanic patients were twice as likely to have a readmission
18 months, 19–24 months, and 25 months or more. The models as Hispanic patients (OR 2.02, 95% CI 1.07, 3.81; Table 2).
were adjusted for age at time of bariatric surgery (< 50, 50–59,
60–69, and 70+ years), sex, race (white, black, other/un-
known), ethnicity (non-Hispanic, Hispanic), and insurance sta- Discussion
tus (Medicaid at either admission, all other insurance). Odds
ratios (OR) and 95% confidence intervals (CI) are reported. All Bariatric surgery continues to be a popular treatment option
analyses were conducted in SAS v9.3 (Cary, NC). for inducing weight loss in morbidly obese patients, especially
as the prevalence of clinically severe obesity is increasing at a
disproportionately high rate [16]. In addition to its effects on
Results weight reduction, bariatric surgery also helps improve chronic
medical problems such as diabetes and sleep apnea, which
There were 330 cases of bariatric surgery followed by a THA helps lower the risk of perioperative complications associated
and 1017 cases followed by a TKA. Most patients were between with TJA surgery [17, 18]. Complications lead to increased
50 and 59 years old (46.4% of THA cohort; 47.0% of TKA costs and hospital resource utilization; Meller et al. reported a
cohort). Patients undergoing THAwere between 22 and 77 years significant increase in total health care resource consumption
old (median 56 years); patients undergoing TKA were between for the morbidly and super obese compared to the non-obese
26 and 86 years old (median 57 years). A majority of patients population undergoing TJA [18].
were female (69.4% THA; 76.4% TKA), white (84.5% THA; Given the increasing prevalence of obesity in TJA patients
82.2% TKA), and non-Hispanic (90.0% THA; 86.6 TKA). and the push to deliver quality care while controlling costs,
Fewer than 10% of patients in both cohorts had Medicaid at bariatric surgery is offered to many morbidly obese patients
either surgical encounter. The largest proportion of TKAs oc- with end-stage arthropathy as a legitimate means for weight
curred more than 2 years following bariatric surgery (37.2%), loss, overall health improvement, and improving their
followed by 7–12 months (19.7%), 13–18 months (19.4%), 19– periroperative risk profile. With the increasing fiscal and so-
24 months (14.2), and zero to 6 months (9.6). Time between cietal pressures on the American health care system, delaying
bariatric surgery and THA was evenly distributed across all 6- elective TJA surgery with the goal of risk mitigation for these
month intervals following bariatric surgery (Table 1). high-risk patients seems both logical and ethical [19].
Theoretically, increasing the time from bariatric surgery to
90-Day Complications elective TJA surgery would increase the benefit of the bariat-
ric procedure by allowing more time for weight loss and im-
Pneumonia, acute renal failure, acute cholecystitis, and central provement of associated medical comorbidities. This study
nervous system problems were removed from the composite demonstrated a significantly reduced risk of 90-day
outcome because they did not occur in our cohort of patients. readmissions among patients undergoing THA greater than
There was no association found between time of bariatric sur- 6 months after bariatric surgery. However, we did not find
gery and THA or TKA and 90-day complications in the mul- an association of time between surgeries and the risk of 90-
tivariable logistic regression analyses. Female patients were day complications for THA patients, or between time from
more likely to have a complication than male patients in the bariatric surgery to TKA and either 90-day complications or
THA (OR 1.82, 95% CI 1.10, 3.00) and TKA (OR 1.56, 95% 90-day readmissions. A possible reason for the effect on
1398 OBES SURG (2018) 28:1395–1401

Table 2 Adjusted odds ratios and


95% confidence intervals for THA TKA
complications and readmissions Characteristics 90-day 90-day 90-day 90-day
at 90-days for patients undergoing complications* readmission complications* readmission
bariatric surgery followed by TJA
Months between bariatric surgery and TJA
0–6 months 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
7–12 months 0.75 (0.38, 1.49) 0.36 (0.17, 0.77) 1.30 (0.76, 2.22) 0.93 (0.51, 1.69)
13–18 months 0.75 (0.35, 1.62) 0.21 (0.08, 0.55) 0.99 (0.58, 1.70) 0.73 (0.39, 1.36)
19–24 months 1.56 (0.69, 3.52) 0.33 (0.13, 0.85) 1.31 (0.74, 2.31) 0.68 (0.35, 1.33)
> 24 months 0.67 (0.33, 1.32) 0.32 (0.15, 0.70) 1.30 (0.79, 2.13) 0.71 (0.41, 1.25)
Age
< 50 years 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
50–59 years 0.79 (0.45, 1.39) 0.69 (0.35, 1.36) 1.17 (0.80, 1.71) 1.04 (0.64, 1.67)
60–69 years 1.43 (0.75, 2.72) 1.12 (0.52, 2.37) 1.46 (0.97, 2.20) 1.19 (0.72, 1.97)
70+ years 0.95 (0.26, 3.45) 1.63 (0.39, 6.75) 3.89 (1.88, 8.05) 1.94 (0.85, 4.40)
Sex
Male 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Female 1.82 (1.10, 3.00) 0.66 (0.37, 1.16) 1.56 (1.12, 2.17) 0.74 (0.51, 1.07)
Race
White 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Black 1.53 (0.67, 3.50) 1.04 (0.37, 2.92) 1.07 (0.67, 1.71) 1.33 (0.78, 2.29)
Other/unknown 0.81 (0.31, 2.11) 0.38 (0.10, 1.46) 1.06 (0.65, 1.75) 0.96 (0.49, 1.88)
Ethnicity
Hispanic 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Non-Hispanic 0.85 (0.37, 1.95) 0.87 (0.32, 2.39) 1.00 (0.66, 1.54) 2.02 (1.07, 3.81)
Insurance
Ever Medicaid 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
All other insurance 1.81 (0.67, 4.86) 0.60 (0.21, 1.74) 0.72 (0.40, 1.31) 0.73 (0.35, 1.51)

*Complications refer to complications that occurred at time of total joint arthroplasty

readmission rates was observed for THA patients, and not for loss and metabolic changes. Previous studies have shown that
TKA patients, may be that there is more subcutaneous fat the metabolic benefits of laparoscopic Roux-en-Y gastric by-
surrounding the hip. The thickness of peri-incisional subcuta- pass (LRYGB)—a malabsorptive procedure—are apparent
neous fat has been correlated with complications after cervical before substantial weight loss occurs, while weight loss occurs
spine and cardiac surgery [20–22], so it can be inferred that before metabolic changes after restrictive procedures such as
weight loss after bariatric surgery would be most likely to LSG [23, 24]. Comparing restrictive and malabsorptive pro-
affect areas of the body with more subcutaneous fat. cedures, Shoar et al. found that LRYGB produced greater
Although our data suggest that waiting more than 6 months long-term weight loss than LSG, though no difference was
after bariatric surgery before undergoing TJA, further studies observed in the rate of reduction of comorbidities [25]. TJA
are needed to be able to make a definitive recommendation on candidates who are referred to bariatric surgeons for consulta-
the optimal timing for TJA following bariatric surgery. tion should be made aware of the differences in time to desired
There are several potential explanations for our results. postop outcome (weight loss, comorbidity improvement) that
First, the time course of patient response to bariatric surgery are associated with the chosen procedure, the severity of their
is unpredictable, and subjective factors that contribute to an chronic medical problems [10], and their age [10, 26]. The
individual’s response are not captured in an administrative amount of excess weight prior to surgery has not been shown
database. Golomb et al. found that the percentage of excess to be correlated with changes in obesity-related comorbidity
weight loss (%EWL) and rates of partial and complete remis- status, further illustrating the multifactorial nature of each pa-
sion of type 2 diabetes mellitus were significantly lower with tient’s response to bariatric surgery.
increased time from laparoscopic sleeve gastrectomy (LSG) There are several limitations to this study, mostly related to
[10]. Additionally, the type of bariatric surgery, restrictive, or the database characteristics. First, we were not able to include
malabsorptive, also affects the observed postoperative weight a subgroup analysis based on the type of bariatric procedure
OBES SURG (2018) 28:1395–1401 1399

performed, restrictive or malabsorptive, because the informa- Conclusion


tion was not available in our database. Secondly, patient BMI
was not consistently reported in the database, and we were Our retrospective study did not show that increasing the
unable to include this information in our analysis. Thirdly, time from bariatric surgery to arthroplasty had any effect
we did not have any information available regarding the nu- on perioperative complications for both TKA and THA.
tritional status of our patients, which may have provided more Our analyses did show a reduced rate of 90-day readmis-
information on observed complication rates. Additionally, our sion for THA, but not for TKA. Based on our results, we
analysis was not limited to patients who underwent bariatric are unable to make a recommendation on the optimal time
surgery specifically for medical optimization after being indi- for TJA surgery after bariatric surgery. The value of bar-
cated for TJA, which may make for a more diverse cohort iatric surgery as part of preoperative medical optimization
because we included any and all bariatric surgery prior to may lie in the nature of the metabolic changes, rather than
TJA. Our analysis was also limited by the fact that our data- the magnitude of weight lost. Further studies are needed to
base consists of patients within a single state, and includes better characterize the temporal relationship of bariatric
only patients who had both procedures, bariatric surgery and and arthroplasty surgeries.
TJA, within the defined time period of the study. Despite these
limitations in sample size, our study reports on one of the Compliance with Ethical Standards:
largest cohorts of TJA patients who have also undergone bar-
Conflict of Interest Dr. Schwarzkopf reports grants and personal fees
iatric surgery. Finally, our stratification of patients by time
from Smith & Nephew, personal fees from Intellijoint. Ms. Lavery reports
from bariatric procedure to TJA was somewhat arbitrary, as no relevant conflicts of interest. Dr. Hooper reports no relevant conflicts
there have been no studies published previously that explicitly of interest. Dr. Parikh reports no relevant conflicts of interest. Dr. Gold
define the expected time course for weight and metabolic reports no relevant conflicts of interest.
changes after bariatric surgery. The strengths of this
Ethical Approval All procedures performed in studies involving human
population-based database are that it includes all payer data
participants were in accordance with the ethical standards of the institu-
for the entire diverse state of California, thereby giving us an tional and/or national research committee and with the 1964 Helsinki
opportunity to evaluate trends on a substantially sized cohort. declaration and its later amendments or comparable ethical standards.

Appendix

Table 3 ICD-9-CM diagnosis


and procedure codes used to Condition ICD-9 code
identify bariatric surgery, total hip
arthroplasty (THA), total knee Total joint arthroplasty (procedure codes)
arthroplasty (TKA), and select Total hip arthroplasty 81.51
complications following Total knee arthroplasty 81.54
THA/TKA
Bariatric surgery (procedure codes)
Laparoscopic vertical (sleeve) gastrectomy 43.82
Open and other partial gastrectomy 43.89
High gastric bypass 44.31
Laparoscopic gastroenterostomy [bypass: 44.38
gastroduodenostomy, gastroenterostomy,
gastrogastrostomy, and laproscopic
gastrojujenostomy without gastrectomy NEC]
Other gastroenterostomy without gastrectomy 44.39
[bypass: gastroduodenostomy,
gastroenterostomy, gastrogastrostomy, and
gastrojujenostomy without gastrectomy NOS]
Laparoscopic gastroplasty [banding: silastic 44.68
vertical banding and vertical banded gastroplasty
(VBG)]
Laparoscopic gastric restrictive procedure 44.95
BMI (diagnosis codes)
Overweight and obese V854, 278.x
1400 OBES SURG (2018) 28:1395–1401

Table 3 (continued)
Condition ICD-9 code

Postoperative complication
Pulmonary embolism [1] 415.1, 415.11, 415.19
Deep vein thrombosis [1] 453.4, 453.40, 453.41, 453.42
Acute myocardial infarction [1] 410.00–410.02, 410.10–410.12, 410.20–410.22,
410.30–410.32, 410.40–410.42, 410.50–410.52,
410.60–410.62, 410.70–410.72, 410.80–410.82,
410.90–410.92
Respiratory failure [1] 518.0, 518.51, 518.52, 518.81, 518.82
Cerebrovascular accident [1] 430, 431, 432.0, 432.1, 432.9, 433, 433.0, 433.00,
433.01, 433.1, 433.10, 433.11, 433.2, 433.20,
433.21, 433.3, 433.30, 433.31, 433.8, 433.80,
433.81, 433.9, 433.90, 433.91, 434, 434.0, 434.00,
434.01, 434.1, 434.10, 434.11, 434.9, 434.90,
434.91
Urinary tract infection [1] 098.0, 098.1, 098.10, 098.19, 599.0, 996.64
Pneumonia [1] 480.0–480.9, 481, 482.0–482.9
Acute renal failure [1] 584.5–584.9, 580.0–580.9, 586
Acute cholecystitis [1] 575.0, 574.00, 574.01
Postoperative blood transfusion [1] Note: paper V58.2, 99.00, 99.02, 99.03, 99.04
provided diagnosis codes of 990.0, but that’s not
right, the procedure code for transfusion is 99.00,
updated based on ICD-9 book (2/8/17)
Central nervous system 997.0, 997.00, 997.01, 997.02, 997.09
Cardiac 997.1
Peripheral vascular disease 997.2
Respiratory 997.3, 997.31, 991.39
GI 997.4
GU 997.5
Hematoma/seroma 998.1, 998.11, 998.12, 998.13
Wound dehiscence 998.0, 998.3, 998.31, 998.32, 998.33
Postoperative infection 998.5, 998.51, 998.59
Postoperative anemia 285.1

1. Werner, B.C., et al., Super obesity is an independent risk factor for complications after primary total hip
arthroplasty. J Arthroplasty, 2017. 32(2): p. 402–406

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