Deciding to have joint replacement surgery can be a tough decision for some individuals to make. When you are overweight and preparing for surgery, the need to lose excessive weight prior to the procedure can make it feel even more overwhelming.
A person may feel fit and healthy at their current body weight, but a patient with a body mass index (BMI) greater than 40, which is considered morbidly obese, is more likely to experience serious complications both during and after surgery than someone of average weight.
“It’s unrealistic to expect an overweight patient to get down to a 35 BMI, as they would have to lose a significant amount of weight, but if they can just lose 30 to 40 pounds, we can proceed with the procedure,” explains Dr. Peter Hanson, an orthopedic surgeon affiliated with Sharp Grossmont Hospital. “At Sharp, we are trying to control the risk of complications and the need for rehospitalization, which directly benefits the patients.”
Why losing weight prior to surgery is important
There are two considerations when it comes to losing weight prior to hip and knee replacement surgery: prevention and treatment.
From a prevention standpoint, losing the weight can cause the joints to hurt less and could even delay the need for surgery. Dr. Hanson adds that if you are considered obese and lose 20% of your weight, the pain in the joints or the progression of arthritis could stop.
When it comes to treatment, replacement surgery is necessary when the deterioration within the joints has become severe. However, with surgery comes risk — more for some people than others.
Just like with diabetes and high blood pressure, weight is a risk factor for surgical complications and the best way to decrease it is through weight loss. What’s more, infection and heart attack are two of the top risks associated with being overweight and having surgery.
“Every minute you're not in the operating room with your knee or your hip open, you're less likely to get infected,” says Dr. Hanson. “If I must do a total hip or knee replacement and it takes me 45 extra minutes because of a person’s weight, that’s 45 additional minutes that they're exposed to blood loss and more apt to get infected.”
If the infection is bad enough, it can lead to additional procedures and to weeks of receiving IV antibiotics that have their own risks. Even with all of the protocols in the operating room — as well as prior to and after surgery — to mitigate the risk of infection, none work as well as losing the required weight.
An additional complication for a patient with obesity during surgery is the administration of anesthesia. The anesthesiologist may have a difficult time due to the patient’s body shape or underlying health conditions that can affect breathing. Locating the veins, ensuring oxygen and airflow is sufficient, and properly positioning the needle are all elements that can be made easier by reducing weight prior to surgery.
The process to losing weight prior to surgery
For someone who is overweight, being told to lose significant weight prior to joint surgery may seem impossible. The pain within the joints reduces the ability to exercise, and the decreasing activity contributes to the additional weight. Working with your physician can help get the process jump-started.
According to Dr. Hanson, the conversation between a patient who is at a healthy weight compared to someone who is not can be very different. “The easiest patients to have a conversation with are those that have researched their procedure and come in at a healthy weight — it then becomes a 10- to 15-minute chat,” he says.
“The discussion with someone who is overweight may be handled differently, as we ease into the topic of weight loss,” Dr. Hanson says. “I spell it out that they must take the weight off. Although many of my patients are unable to exercise because of their medical condition and the additional weight, I tell them it is not always about exercise, but also diet control.”
For these patients, he recommends they read “The Obesity Code,” a book that introduces the concept of intermittent fasting and minimizing carbohydrates. While many may have tried and failed with different diets, using the book’s guidance to lose 50 or so pounds before the operation might just be the starting point needed.
Another way for a patient to stay on track during the weight loss process is by working with their primary care provider. There are some insurance plans that cover weight loss programs, and their doctor can assist them in registering.
“As I don’t want them to weigh themselves at home, I will write a letter to their primary physician explaining that the patient needs a joint replacement, but must first lose a certain amount of weight,” Dr. Hanson says. “Their doctor weighs them and sends me a report. After they have lost the required weight, we will schedule their surgery.”
Dr. Hanson also cautions that if weight is regained prior to surgery, then it will likely be canceled until the patient is able to maintain the required lower weight.
Understanding the impact of losing weight prior to surgery
A person living with a BMI of 45 will most likely not see the benefit of a surgery that will improve their joint pain because of the complications that may come with it. The process of losing weight must start prior to the surgery, whether it’s through eating healthier or exercise, to reap the rewards.
“It’s more than improving the patient’s life span,” explains Dr. Hanson. “It’s about improving what we call the health span — making it so you're healthier in your 60s, 70s and 80s because you can walk, cycle and go to the gym. It’s about living longer and living better."