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Feature Article

Youth, obesity and worn knees. A trifecta of trouble

David Campbell
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Referral for knee replacement surgery should be considered when patients have stabilised their weight after a weight-reduction program, optimised their medical health and have a reasonable risk profile for surgery. Morbidly obese patients have a higher prevalence of complications in all studies. The risk profile of a morbidly obese patient is dominated by their weight-related comorbidities and less influenced by age, and is more similar to that of a much older medically infirm patient than to a nonobese patient of their own age. 

Once it has been decide that surgery should be performed, patients should be optimised in preparation for it. Paradoxically weight loss is associated with malnutrition and muscle atrophy, and maintenance of muscle tone with nonweight-bearing exercises such as swimming and nonimpact gym work is an important adjunct to weight loss interventions. 

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Conclusions

Osteoarthritis and knee pain are anticipated associations with morbid obesity. Disabling knee pain in a morbidly obese patient may be the focus of the patient’s attention but is merely the tip of the iceberg of a host of medical and psychological problems. Knee replacement surgery may be the conclusion of the therapeutic spectrum but has considerable risk and it would be remiss not to optimise the patient’s global comorbidities. A multidisciplinary program aimed at normalising body mass and maintaining muscle tone is likely to reduce knee pain and improve lifespan. Symptomatic knee osteoarthritis will inevitable progress and surgery is likely to be required and repeated several times over the patient’s lifespan.      MT

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COMPETING INTERESTS: None.

 

References

1. World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO consultation (WHO Technical Report Series 894). Geneva: WHO; 2000; reprinted 2004. 
2. Murphy L, Schwartz TA, Helmick CG, et al. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum 2008; 59: 1207-1213. 
3. Hart DJ, Spector TD. The relationship of obesity, fat distribution and osteoarthritis in women in the general population: the Chingford Study. J Rheumatol 1993;  20: 331-335.
4. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Hip and knee arthroplasty. Annual Report 2014. Adelaide: AOANJRR; 2014.
5. Canadian Institute for Health Information (CIHI). Hip and knee replacements in Canada – Canadian Joint Replacement Registry 2008–2009 Annual Report. Ottowa, Ont.: CIHI; 2009.
6. Andersen RE, Crespo CJ, Bartlett SJ, Bathon JM, Fontaine KR. Relationship between body weight gain and significant knee, hip and back pain in older Americans. Obes Res 2003; 11: 1159-1162.
7. Felson DT, Zhang Y, Anthony JM, Naimark A, Anderson JJ. Weight loss reduces the risk for symptomatic knee osteoarthritis in women. The Framingham Study. Ann Intern Med 1992; 116: 535-539.

Further reading

Samson AJ, Mercer GE, Campbell DG. Total knee replacement in the morbidly obese: a literature review. ANZ J Surg 2010; 80: 595-599. 

Pages

Associate Professor Campbell is an orthopaedic surgeon in private practice in Adelaide, SA, specialising in joint replacement.