The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 11

Current Concepts Review | June 06, 2012

Impact of Obesity on Orthopaedics

Sanjeev Sabharwal, MD¹; Michael Z. Root¹

¹ Department of Orthopedics, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Doctor's Office Center, 90 Bergen Street, Suite 7300, Newark, NJ 07103. E-mail address for S. Sabharwal: sabharsa@umdnj.edu

View Disclosures and Other Information

Disclosure statement for author(s): PDF

Investigation performed at the University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey

J Bone Joint Surg Am, 2012 Jun 06;94(11):1045-1052. doi: 10.2106/JBJS.K.00330

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Abstract

The prevalence of obesity among children and adults is increasing worldwide.

There are substantial health risks and financial costs associated with the obesity epidemic that impact the practice of orthopaedic surgery.

Patients with increased body mass index are more prone to sustaining distal extremity injuries than are those with a normal body mass index.

Obese individuals are more likely than nonobese individuals to seek treatment for osteoarthritis of the knee.

Figures in this Article

Introduction

Body mass index (BMI) is defined as the weight in kilograms divided by the square of the height in meters (kg/m²)¹. Adults with a BMI of 25 to 29.9 are considered overweight, whereas those with a BMI of ≥30 are regarded as obese. Morbid obesity is defined as a BMI of ≥40². For children and adolescents (two to nineteen years old), overweight is defined as a BMI that is between the 85th and 95th percentile, whereas obesity is characterized by a BMI of ≥95th percentile for children of the same age and sex³.

Obesity is a health issue of increasing prevalence. On the basis of global estimates by the World Health Organization in 2008, approximately 1.5 billion adults (at least twenty years old) were overweight and 500 million were obese¹. According to the Centers for Disease Control and Prevention (CDC), more than seventy-two million adults in the United States in 2010 were obese. Of note, no state in the U.S. had an adult obesity rate of less than the national goal of 15%, with Mississippi having the highest prevalence of obesity among adults at 34.4%. Obesity also affects approximately 17% of all children and adolescents in the United States, which is triple the rate from just one generation ago³. Once considered a problem only in high-income countries, obesity is now also on the rise in low and middle-income countries, particularly in urban settings¹.

Pathophysiology

Factors such as sedentary lifestyle, excessive consumption of foods with high caloric content, and lower socioeconomic levels are often associated with obesity. However, a causal relationship between these variables and obesity has not been firmly established^4,5.

On a molecular level, two fat-derived hormones (adipokines), leptin and adiponectin, have been implicated in the pathophysiology of obesity, but their precise mode of action remains speculative^6-8. Obese individuals are noted to have an elevated serum leptin level, which is thought to promote leptin resistance, thereby increasing the susceptibility to diet-induced obesity and metabolic impairment⁷. Unlike leptin, a strong negative correlation between plasma adiponectin concentration and BMI has been noted⁹. Adiponectin plays a key role in glucose regulation and fatty acid catabolism⁸. Decreased levels of adiponectin are associated with insulin resistance and type-II diabetes, a major obesity-related disease⁹.

Financial Burden

The rising levels of obesity are estimated to cause health-system costs comparable with those associated with twenty years of natural aging¹⁰, with both direct and indirect expenses to society. On the basis of 2008 estimates, the annual medical costs of obesity in the U.S. were $147 billion¹¹. Additionally, obese individuals are more likely than their nonobese peers to have work limitations¹², sustain unintentional injuries, and file Workers’ Compensation claims^13-15. The indirect costs of diabetes, one of the most devastating consequences of obesity, are related to lower returns on education, unemployment, decreased household wages, premature retirement, and increased dependence on welfare¹⁰.

For the purpose of medical billing, the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) has been updated to include various diagnostic codes for obesity. For instance, “obesity, unspecified” is coded as 278.00 and the code for morbid obesity is 278.01. Typically requiring additional equipment and personnel, the preoperative and intraoperative orthopaedic care of obese patients often leaves the surgeon and/or support staff inadequately compensated for their extra time and effort. Not only was supplementary compensation for treating obese patients limited and inconsistent, but a substantial decline in inflation-adjusted physician reimbursement for performing hip and knee arthroplasties was noted in the comparison of compensation received in 1990 and that received in 2005 in one orthopaedic practice in the U.S.^11,16.

Radiographic Imaging

Obesity can impact image acquisition with consequent attenuation of the quality of the radiograph¹⁷. In order to adequately visualize the underlying skeleton in an obese patient, adjustments are made to the kilovoltage peak and milliamperes per second that increase the radiation dose¹⁸. While utilization of digital radiography has allowed enhanced visualization due to the capability to adjust the image quality at the workstation monitor after image acquisition¹⁷, the increased distance from the bones to the x-ray cassette can also cause radiographic magnification and influence linear measurements in a large patient¹⁹. When intraoperative supine fluoroscopy was compared with full-length standing radiographs of the lower extremity for assessing lower limb alignment, an increase in BMI was associated with a greater magnitude of discrepancy between the two imaging studies²⁰.

From an advanced imaging perspective, an individual's waist size and body weight are more relevant than total body fat or BMI. Commonly used computed tomography (CT) scanners have weight limits of 450 lb (202.5 kg) and a maximum gantry diameter of 70 cm. However, access to emergency CT and magnetic resonance imaging (MRI) scanners may be limited for such large patients. On the basis of a national survey, only 10% of U.S. hospitals with emergency departments had large-weight capacity (>202.5 kg) CT scanners and 8% had large-capacity MRI scanners available. The larger-capacity CT scanners that are typically used in veterinary centers are a potential alternative for a massively obese patient¹⁷. While such scanners are more readily available in veterinary schools, policy regulations have restricted human access to the majority of animal facilities²¹.

Perioperative Considerations

Obese individuals are not only more prone to premature death than are normal-weight individuals but are also predisposed to cardiovascular diseases such as hypertension, stroke, coronary artery disease, and venous thromboembolism as well as certain malignancies, type-II diabetes, sleep apnea, liver disease, pancreatitis, and some psychiatric ailments^22-24. The goal of preoperative assessment of the obese patient is to identify and address any modifiable conditions to minimize perioperative complications. Furthermore, previously obese individuals who have undergone bariatric surgery are prone to develop nutritional deficiencies, including protein-calorie malnutrition as well as vitamin and mineral deficiencies^25,26. Preoperative assessment of the nutritional status and coagulation profile may be indicated in such patients.

Skilled anesthetic assistance and availability of a wide range of equipment to facilitate intubation are imperative. As difficult intubation is more common among those with a BMI of >35^27,28, use of fiber-optic intubation may facilitate anesthetic management in extremely obese individuals²⁹. In a comparison of obese and nonobese children undergoing general anesthesia for dental procedures, slightly higher incidences of intraoperative oxygen desaturation and unexpected overnight hospitalization were noted in the obese group³⁰. Regional anesthesia has several potential advantages over general anesthesia in obese patients, including minimal airway manipulation, avoidance of drugs with cardiopulmonary depression, reduced prevalence of postoperative nausea and vomiting, and better postoperative pain control. However, difficulty in palpation of osseous landmarks, need for longer needles, and different dosing requirements make achieving a successful peripheral and neuraxial blockade challenging in obese patients^25,31,32. Pharmacokinetic considerations for various medications, including antibiotics and analgesics, should also be recognized because of the influence of increased adiposity on the volume of distribution of certain drugs^33-35. Dosing for analgesic medications should be based on ideal body weight rather than total body weight³⁵.

Despite the extra soft-tissue padding, obese patients are predisposed to developing pressure sores, leg and thigh compartment syndromes, nerve palsies, and scalp alopecia related to intraoperative positioning^36,37. Trendelenburg, lithotomy, and prone positions that typically restrict chest and abdominal excursion can further compromise ventilation and are poorly tolerated by obese individuals. A lateral position, typically with dual beanbags, is well suited for such patients since the bulk of panniculus adiposus is displaced away from the abdomen, allowing greater diaphragmatic excursion and easier access to the hip and leg³⁵. If an obese patient exceeds the weight capacity of the operating-room table, two tables can be placed in a head-to-head or head-to-foot position. However, with this arrangement, obtaining a lateral image of the extremity with use of fluoroscopy is challenging.

Because obesity is an independent risk factor for venous thromboembolism and pulmonary embolism, mechanical and/or chemical prophylaxis is strongly recommended when treating such patients^38-41. Each patient should be stratified by risk, and the choice of thromboembolic prophylaxis should be individualized on the basis of the best available evidence. Application of graduated compression stockings in an obese individual can be challenging, and use of correctly sized knee-length stockings, as opposed to thigh-length stockings, has been recommended for these patients⁴². While there are several options for chemoprophylaxis, the dosage of agents such as low-molecular-weight heparin is debatable and may have to be increased in an obese patient⁴³. The diagnosis of deep venous thrombosis in the proximal part of the lower extremity with use of ultrasound may be less reliable because of attenuation of the ultrasound beams by the increased adiposity, compromising the image quality¹⁷. In addition to their susceptibility to develop lower-extremity thrombosis, obese patients are also at an increased risk for developing upper-extremity deep venous thrombosis⁴⁴.

Impact on Pediatric Patients

Childhood obesity is associated with poorer quality of life and impaired mobility⁴⁵. The prevalence of back and lower-extremity pain, particularly at the knee and foot, is also higher among obese children than nonobese children^45,46. Heavier children typically display a slower, more tentative gait, spend less time in single-leg stance, require a greater amount of energy⁴⁷, and exert increased forefoot plantar pressure while walking than do children with normal weight^48,49.

It is well known that compressive forces across the growth plate can cause growth inhibition and may lead to angular deformities of the lower limb because of asymmetric growth at the physis. While the pathogenesis of Blount disease is likely multifactorial, there is a strong mechanical basis^50,51. A positive correlation between BMI and the magnitude of genu varum was noted among children with untreated early-onset Blount disease (r = 0.74, p < 0001) and those with a BMI of ≥40, irrespective of age of onset for Blount disease (r = 0.78, p = 0.0002)⁵². An obese adolescent with Blount disease is also at risk for implant failure following guided growth treatment of the proximal part of the tibia⁵³. A BMI of ≥45 in adolescents with Blount disease was associated with limited improvement of genu varum following lateral hemiepiphyseodesis⁵⁴. Besides a predisposition for Blount disease, obese children may also have an increased prevalence of genu valgum and recurvatum^55,56. Obese children typically have advanced skeletal maturity^57,58. Consequently, assessing skeletal age before operative realignment of the lower extremity can help to predict remaining growth and optimize clinical outcome.

The rising prevalence of childhood obesity may also affect the clinical presentation of slipped capital femoral epiphysis^59,60. Not only is the reported prevalence of slipped capital femoral epiphysis increasing^61,62, but heavier children also seem to be presenting with the disorder at an earlier age^61,63, and with a higher prevalence of bilateral slipped capital femoral epiphysis, than are those with a normal weight^61,64.

Injury patterns among obese children are quite distinct from those among their lighter-weight peers. While obese children involved in high-velocity trauma are less likely to sustain serious head injuries⁶⁵, they are more likely to have fractures of the distal portion of an extremity^66,67. Fractures of the distal part of the forearm following minor trauma are also more common among obese adolescents, likely related to a combination of suboptimal bone health status, increased force transmission, and poor balance in the heavier child^45,68-71.

Obese children undergoing operative treatment of femoral shaft fractures are predisposed to postoperative complications, such as fracture malunion, refracture, and poor wound-healing⁷². The potential for increased force transmission across the injured lower extremity can also influence the choice of implants used for operative fixation of long bones. While an increased prevalence of femoral shaft malunion with the use of flexible nails in children who weighed ≥50 kg has been reported^73,74, other investigators have found acceptable outcomes in heavier children with length-stable fracture patterns⁷⁵. The use of different implants, such as rigid interlocking nails inserted via the greater trochanter, may be indicated in the treatment of heavier adolescents, especially in those with length-unstable femoral shaft fractures⁷⁶.

The ability to transmit corrective forces to the scoliotic spine through the ribs and soft tissues may be compromised in overweight adolescents. Use of an underarm brace for treating moderately severe adolescent idiopathic scoliosis in skeletally immature individuals was less effective among overweight adolescents⁷⁷. In another retrospective analysis, overweight adolescents with idiopathic scoliosis undergoing operative correction had greater thoracic kyphosis, but no demonstrable increase in the perioperative mortality or morbidity compared with their normal-weight peers⁷⁸.

Trauma

Obese persons are predisposed to certain patterns of musculoskeletal injuries and have an increased mortality rate as victims of high-velocity trauma^79,80. On the basis of a cross-sectional study of the rates of medically attended injury among adults in the U.S., the odds of sustaining an injury were 15% (for those with a BMI of 25 to 30) to 48% (for those with a BMI of ≥40) greater among those with excess weight⁸¹. Likely because of the cushioning effect of adipose tissue, obese individuals are less likely to sustain abdominal and pelvic injuries following motor vehicle accidents⁷⁹. However, possibly related to the increased amount of energy transferred distally, they are more predisposed to sustain severe fracture patterns of the pelvis⁸², distal aspect of the femur⁸³, ankle⁸⁴, and calcaneus⁸⁵, as well as internal degloving injuries⁸⁶. Even at low velocities, substantial energy can be dissipated in the obese individual, with a tendency for comminuted fractures and soft-tissue damage, especially involving the distal end of the long bones⁸³. Those with an increased BMI are also prone to knee dislocations following low-energy trauma⁸⁷ and have a high prevalence of associated popliteal artery injury requiring repair, with a substantial rate of postoperative complications including above-the-knee amputations⁸⁸.

The relationship between obesity and bone mineral density remains unclear^89-92. Although obese and overweight adolescents were noted to have higher bone mineral content than normal-weight counterparts, the mean bone mineral content, after adjustment for total body mass, was substantially lower than that in the control group⁹³. Thus, the observed increased bone density noted in obese individuals may not be adequate to overcome the substantially greater forces that are generated, for instance, when they fall on an outstretched upper extremity^69,93. Although postmenopausal obese women report more falls, they have fewer fractures of the hip, possibly related to the increased soft-tissue padding overlying the proximal part of the femur compared with their nonobese counterparts⁹⁴. Among elderly patients who sustain hip fractures, those with intertrochanteric fractures tend to be overweight, whereas those with intracapsular femoral neck fractures are leaner⁹⁵. In addition to age-related bone loss, the use of a high-protein omnivorous diet for effective weight loss in overweight and obese postmenopausal women has been noted to decrease bone mineral density and increase the risk for osteoporosis⁹⁶.

Given the large soft-tissue mass in the proximal aspect of the thigh, the obese patient is at a higher risk than a normal-weight patient for an undetected ipsilateral fracture of the femoral neck along with a femoral shaft fracture. Besides greater vigilance, advanced imaging studies, including a thin-slice CT scan, may be indicated in this subset of patients⁹⁷. Intraoperative arthrography has been utilized to improve visualization and allow safe and accurate placement of implants during operative fixation of femoral neck fractures in obese patients⁹⁸. To minimize operative time, blood loss, and radiation exposure, obesity may be a relative indication to use a retrograde instead of an antegrade approach for intramedullary nailing for femoral shaft fractures^99,100. If antegrade nailing is chosen, use of lateral positioning of the patient and a trochanteric entry portal may facilitate safe access to the proximal part of the femur^35,101. Maximizing the nail diameter and use of static locking with multiple screws may be warranted in these large patients, given the additional difficulty with adhering to partial weight-bearing instructions^97,99. Obese patients are also predisposed to postoperative infections and loss of fracture reduction, especially following fixation of ankle¹⁰², pelvic, and acetabular fractures^103-105.

Lower-Extremity Reconstruction

While an association between obesity and the need for subsequent total hip arthroplasty and total knee arthroplasty has been established, the evidence is more robust for the knee than for the hip^106-112. On the basis of data from the Canadian Joint Replacement Registry, the need for having total knee arthroplasty was 8.5 times higher in patients with a BMI of >30, 18.7 times higher in those with a BMI of >35, and 32.7 times higher in those with a BMI of >40 compared with individuals of normal weight¹¹³. Moreover, morbidly obese patients seek treatment for hip and knee replacement a decade earlier than those with a normal BMI¹¹⁴. According to a recent meta-analysis of observational studies, weight loss may reduce the risk for developing symptomatic knee osteoarthritis among adults¹¹⁵.

Total hip arthroplasty can be challenging in obese patients because the extensive adipose tissue can obscure osseous landmarks, compromise optimal implant positioning, and prolong operative time^116,117. Special instruments such as curved reamers and modified retractors that are typically utilized for minimally invasive surgery can be helpful when total hip arthroplasty is performed in these patients. There is conflicting evidence regarding the increased propensity for postoperative complications such as wound infection^116,118-120 and the need for revision arthroplasty^120-122. On the basis of a retrospective review of 6108 patients who underwent primary hip or knee arthroplasty, those with a BMI of >50 were twenty-one times more likely to develop a postoperative deep infection¹²³. In a case-control study of 4420 patients who underwent total hip arthroplasty, the obese subgroup (a BMI of >30) with uncemented cups had an increased risk of early acetabular component failure compared with those with a BMI of <25 (odds ratio, 1.41; 95% confidence interval, 1.03 to 1.91). In contrast, such predisposition for acetabular component loosening was not noted in those with cemented components (p = 0.55). Since implant stability is necessary to achieve osseointegration and long-lasting fixation of uncemented acetabular components, the higher stress exerted at the prostheses-bone interface may predispose the heavier patient to loosening of the uncemented acetabular implant¹²⁴.

The morbidly obese patient is particularly prone to intraoperative complications following total knee arthroplasty. These potential risks include avulsion of the medial collateral ligament, varus malalignment of the components when extramedullary guides are used, postoperative infection^125,126, and patellofemoral pain with associated radiolucencies and periprosthetic patellar fractures^19,127,128. Overweight patients with medial compartment knee arthritis are more likely than patients with a normal weight to have anterior knee pain, perhaps secondary to increased stresses at the patellofemoral joint¹²⁹, and to develop early implant failure necessitating revision surgery¹³⁰ following both unicompartmental knee arthroplasty and valgus high tibial osteotomy^131,132. After undergoing total knee arthroplasty, obese individuals, especially those with a BMI of >40, typically have lower functional scores than their nonobese peers^133-136.

Whether having bariatric surgery prior to undergoing elective joint replacement decreases perioperative morbidity remains unclear. Most obese patients do not lose weight following total joint arthroplasty of the hip or knee and thus need to be appropriately counseled preoperatively^137-142.

Back Pain and Disc Degeneration

Obese individuals tend to have an increased prevalence of self-reported pain in multiple body parts¹⁴³. Although the association between low-back pain and obesity has been noted by several investigators^143-145, firm conclusions regarding causality cannot be drawn at this time. Factors such as maladaptive coping behaviors, functional impairment, psychiatric comorbidities, and general health status were found to be more reliable predictors of the development of persistent disabling low-back pain than was the individual's BMI¹⁴⁶. The distress voiced by a patient with back pain, especially with a work-related injury claim, may be a surrogate complaint that is associated more closely with certain psychosocial covariates, including job dissatisfaction, impaired coping skills, and lower socioeconomic status in resource-advantaged countries, than with his or her body weight^147,148. Thus, to attribute low back pain to an individual being overweight or obese may be oversimplistic, and a more comprehensive biopsychosocial approach may be warranted, especially for those who are seeking compensation for chronic disabling occupational spinal discomfort¹⁴⁹. Perhaps certain personality traits and socioeconomic attributes predispose some individuals to both obesity^150,151 and musculoskeletal pain^148,149, although further investigation into this complex relationship is needed.

The effect of increased body weight on lumbar disc degeneration as noted on MRI scans also remains unknown, as some studies have suggested a protective influence¹⁵², while others have suggested an increased propensity to disc degeneration among obese individuals^144,153,154. Despite successful decompressive surgery for neurogenic claudication secondary to lumbar stenosis, the majority of overweight and obese patients maintained or increased their body weight at a mean follow-up of thirty-four months. These findings suggest that obesity may be an independent disease entity and not simply a function of symptomatic spinal stenosis¹⁵⁵.

Whether an obese adult patient undergoing traditional elective lumbar spine surgery for degenerative conditions is prone to a higher rate of perioperative complications is also controversial^37,156-158. Minimally invasive approaches to the lumbar spine appear promising in facilitating exposure and minimizing complications in carefully selected obese patients^159-161. However, given the potential for selection bias, steep learning curve, and need for special equipment when minimally invasive approaches to the spine are performed in obese individuals, multicenter studies with long follow-up periods are warranted.

Arthroscopy

Obese individuals have a higher rate of meniscal tears and rotator cuff tendinitis than do nonobese patients, often requiring arthroscopic debridement and repair³⁵. Placement of portals for knee arthroscopy can be challenging because of the difficulty in palpating the osseous landmarks. Longer instruments typically used for shoulder and hip arthroscopies and accessory portals, including the posteromedial and transpatellar portals, may be required for adequate visualization of the knee in morbidly obese patients^162,163. The clinical outcome of arthroscopic debridement for isolated medial compartment osteoarthritis of the knee is also worse in an obese patient than in a nonobese patient^164,165. Thromboembolic complications following arthroscopic knee surgery have also been reported, and routine chemoprophylaxis with low-molecular-weight heparin has been recommended by some¹⁶⁶. However, further studies may be needed before firm recommendations can be made for the prevention of thromboembolism in obese individuals.

Upper-Extremity Disorders

Obese persons may be less efficient when performing activities that require repetitive upper-limb movements and at a higher risk for sustaining injuries than are their normal-weight counterparts^167,168. Obesity is a known risk factor for the development of carpal tunnel syndrome^167-171, with lack of improvement in median nerve conduction velocities despite weight reduction¹⁷². In a case-control study, an association was noted between increasing BMI and the need for operative treatment of rotator cuff tendinitis among middle-aged individuals¹⁶³. While improvement in pain and function was noted in the majority of morbidly obese patients undergoing shoulder arthroplasty, overall results were inferior to those reported for normal-weight individuals¹⁷³.

Future Directions

Obesity is a potentially modifiable condition that can affect the overall health and function of an individual. Given the rising prevalence of obesity worldwide, the practice of orthopaedics is impacted in numerous ways. Orthopaedic organizations such as the American Academy of Orthopaedic Surgeons and the Pediatric Orthopaedic Society of North America have initiated public education campaigns to increase awareness of the ill effects of obesity and the importance of physical activity, nutrition, and weight-bearing exercises. While preventing obesity is ideal, it is a daunting task that will require major contributions not only from health-care workers but also from family members, employers, and policy makers. In order to treat obese patients effectively, the practicing orthopaedic surgeon should be aware of the unique challenges involved in managing patients with this condition.

World Health Organization. Obesity and overweight: fact sheet N°311. Updated 2011 Mar. www.who.int/mediacentre/factsheets/fs311/en/. Accessed 2011 Feb 27.

Centers for Disease Control and Prevention. Defining overweight and obesity. Updated 2010 Jun 21. http://www.cdc.gov/obesity/defining.html. Accessed 2011 Feb 27.

Centers for Disease Control and Prevention. Basics about childhood obesity. Updated 2011 Apr 26. http://www.cdc.gov/obesity/childhood/basics.html. Accessed 2011 Feb 27.

Lobstein T; Baur L; Uauy R; IASO International Obesity TaskForce. Obesity in children and young people: a crisis in public health. Obes Rev. 2004 May;5 Suppl 1:4-104.

Nielsen TL; Wraae K; Brixen K; Hermann AP; Andersen M; Hagen C. Prevalence of overweight, obesity and physical inactivity in 20- to 29-year-old, Danish men. Relation to sociodemography, physical dysfunction and low socioeconomic status: the Odense Androgen Study. Int J Obes (Lond). 2006 May;30( 5):805-15.

Achike FI; To NH; Wang H; Kwan CY. Obesity, metabolic syndrome, adipocytes and vascular function: a holistic viewpoint. Clin Exp Pharmacol Physiol. 2011 Jan;38( 1):1-10. doi: 10.1111/j.1440-1681.2010.05460.x.

Zhang Y; Scarpace PJ. The role of leptin in leptin resistance and obesity. Physiol Behav. 2006 Jun 30;88( 3):249-56. Epub 2006 Jun 16.

Aronne LJ; Isoldi KK. Overweight and obesity: key components of cardiometabolic risk. Clin. Cornerstone. 2007;8( 3):29-37.

Kawano J; Arora R. The role of adiponectin in obesity, diabetes, and cardiovascular disease. J Cardiometab Syndr. 2009 Winter;4( 1):44-9.

Yach D; Stuckler D; Brownell KD. Epidemiologic and economic consequences of the global epidemics of obesity and diabetes. Nat Med. 2006 Jan;12( 1):62-6. Erratum in: Nat Med. 2006 Mar;12(3):367.

Russell GV; Pierce CW; Nunley L. Financial implications of obesity. Orthop Clin North Am. 2011 Jan;42( 1):123-7, vii.

Hertz RP; Unger AN; McDonald M; Lustik MB; Biddulph-Krentar J. The impact of obesity on work limitations and cardiovascular risk factors in the U.S. workforce. J Occup Environ Med. 2004 Dec;46( 12):1196-203.

McCarthy LH; Bigal ME; Katz M; Derby C; Lipton RB. Chronic pain and obesity in elderly people: results from the Einstein aging study. J Am Geriatr Soc. 2009 Jan;57( 1):115-9. Epub 2008 Nov 19.

Pollack KM; Sorock GS; Slade MD; Cantley L; Sircar K; Taiwo O; Cullen MR. Association between body mass index and acute traumatic workplace injury in hourly manufacturing employees. Am J Epidemiol. 2007 Jul 15;166( 2):204-11. Epub 2007 May 7.

Ostbye T; Dement JM; Krause KM. Obesity and Workers’ Compensation: results from the Duke Health and Safety Surveillance System. Arch Intern Med. 2007 Apr 23;167( 8):766-73.

Fehring TK; Odum SM; Griffin WL; Mason JB; McCoy TH. The obesity epidemic: its effect on total joint arthroplasty. J Arthroplasty. 2007 Sep;22( 6 Suppl 2):71-6. Epub 2007 Jul 26.

Uppot RN. Impact of obesity on radiology. Radiol Clin North Am. 2007 Mar;45( 2):231-46.

Yanch JC; Behrman RH; Hendricks MJ; McCall JH. Increased radiation dose to overweight and obese patients from radiographic examinations. Radiology. 2009 Jul;252( 1):128-39. Epub 2009 Apr 29.

Booth RE Jr. Total knee arthroplasty in the obese patient: tips and quips. J Arthroplasty. 2002 Jun;17( 4 Suppl 1):69-70.

Sabharwal S; Zhao C. Assessment of lower limb alignment: supine fluoroscopy compared with a standing full-length radiograph. J Bone Joint Surg Am. 2008 Jan;90( 1):43-51.

Ginde AA; Foianini A; Renner DM; Valley M; Camargo CA Jr. The challenge of CT and MRI imaging of obese individuals who present to the emergency department: a national survey. Obesity (Silver Spring). 2008 Nov;16( 11):2549-51.

Centers for Disease Control and Prevention. CDC vital signs. Adult obesity: obesity rises among adults. Updated 2010 Aug 3. http://www.cdc.gov/vitalsigns/AdultObesity/index.html. Accessed 2011 Feb 27.

Li Z; Bowerman S; Heber D. Health ramifications of the obesity epidemic. Surg Clin North Am. 2005 Aug;85( 4):681-701, v.

Berrington de Gonzalez A; Hartge P; Cerhan JR; Flint AJ; Hannan L; MacInnis RJ; Moore SC; Tobias GS; Anton-Culver H; Freeman LB; Beeson WL; Clipp SL; English DR; Folsom AR; Freedman DM; Giles G; Hakansson N; Henderson KD; Hoffman-Bolton J; Hoppin JA; Koenig KL; Lee IM; Linet MS; Park Y; Pocobelli G; Schatzkin A; Sesso HD; Weiderpass E; Willcox BJ; Wolk A; Zeleniuch-Jacquotte A; Willett WC; Thun MJ. Body-mass index and mortality among 1.46 million white adults. N Engl J Med. 2010 Dec 2;363( 23):2211-9.

Ingrande J; Brodsky JB; Lemmens HJ. Regional anesthesia and obesity. Curr Opin Anaesthesiol. 2009 Oct;22( 5):683-6.

Thaisetthawatkul P. Neuromuscular complications of bariatric surgery. Phys Med Rehabil Clin N Am. 2008 Feb;19( 1):111-24, vii.

Juvin P; Lavaut E; Dupont H; Lefevre P; Demetriou M; Dumoulin JL; Desmonts JM. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003 Aug;97( 2):595-600, table of contents.

Lundstrøm LH; Møller AM; Rosenstock C; Astrup G; Wetterslev J. High body mass index is a weak predictor for difficult and failed tracheal intubation: a cohort study of 91,332 consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database. Anesthesiology. 2009 Feb;110( 2):266-74.

Fujinaga A; Fukushima Y; Kojima A; Sai Y; Ohashi Y; Kuzukawa A; Seto T; Nosaka S. Anesthetic management of an extremely obese patient. J Anesth. 2007;21( 2):261-4. Epub 2007 May 30.

Setzer N; Saade E. Childhood obesity and anesthetic morbidity. Paediatr Anaesth. 2007 Apr;17( 4):321-6.

Cotter JT; Nielsen KC; Guller U; Steele SM; Klein SM; Greengrass RA; Pietrobon R. Increased body mass index and ASA physical status IV are risk factors for block failure in ambulatory surgery—an analysis of 9,342 blocks. Can J Anaesth. 2004 Oct;51( 8):810-6.

Nielsen KC; Guller U; Steele SM; Klein SM; Greengrass RA; Pietrobon R. Influence of obesity on surgical regional anesthesia in the ambulatory setting: an analysis of 9,038 blocks. Anesthesiology. 2005 Jan;102( 1):181-7.

Bearden DT; Rodvold KA. Dosage adjustments for antibacterials in obese patients: applying clinical pharmacokinetics. Clin Pharmacokinet. 2000 May;38( 5):415-26.

Casati A; Putzu M. Anesthesia in the obese patient: pharmacokinetic considerations. J Clin Anesth. 2005 Mar;17( 2):134-45.

Guss D; Bhattacharyya T. Perioperative management of the obese orthopaedic patient. J Am Acad Orthop Surg. 2006 Jul;14( 7):425-32.

Jupiter JB; Ring D; Rosen H. The complications and difficulties of management of nonunion in the severely obese. J Orthop Trauma. 1995;9( 5):363-70.

Patel N; Bagan B; Vadera S; Maltenfort MG; Deutsch H; Vaccaro AR; Harrop J; Sharan A; Ratliff JK. Obesity and spine surgery: relation to perioperative complications. J Neurosurg Spine. 2007 Apr;6( 4):291-7.

Eichinger S; Hron G; Bialonczyk C; Hirschl M; Minar E; Wagner O; Heinze G; Kyrle PA. Overweight, obesity, and the risk of recurrent venous thromboembolism. Arch Intern Med. 2008 Aug 11;168( 15):1678-83.

Lucena J; Rico A; Vázquez R; Marín R; Martínez C; Salguero M; Miguel L. Pulmonary embolism and sudden-unexpected death: prospective study on 2477 forensic autopsies performed at the Institute of Legal Medicine in Seville. J Forensic Leg Med. 2009 May;16( 4):196-201.

Meissner MH; Chandler WL; Elliott JS. Venous thromboembolism in trauma: a local manifestation of systemic hypercoagulability?J Trauma. 2003 Feb;54( 2):224-31.

Memtsoudis SG; Besculides MC; Gaber L; Liu S; González Della Valle A. Risk factors for pulmonary embolism after hip and knee arthroplasty: a population-based study. Int Orthop. 2009 Dec;33( 6):1739-45. Epub 2008 Oct 17.

Winslow EH; Brosz DL. Graduated compression stockings in hospitalized postoperative patients: correctness of usage and size. Am J Nurs. 2008 Sep;108( 9):40-50; quiz 50-1.

Lazar MA; Plocher EK; Egol KA. Obesity and its relationship with pelvic and lower-extremity orthopedic trauma. Am J Orthop (Belle Mead NJ). 2010 Apr;39( 4):175-82.

Blom JW; Doggen CJ; Osanto S; Rosendaal FR. Old and new risk factors for upper extremity deep venous thrombosis. J Thromb Haemost. 2005 Nov;3( 11):2471-8.

Taylor ED; Theim KR; Mirch MC; Ghorbani S; Tanofsky-Kraff M; Adler-Wailes DC; Brady S; Reynolds JC; Calis KA; Yanovski JA. Orthopedic complications of overweight in children and adolescents. Pediatrics. 2006 Jun;117( 6):2167-74.

Stovitz SD; Pardee PE; Vazquez G; Duval S; Schwimmer JB. Musculoskeletal pain in obese children and adolescents. Acta Paediatr. 2008 Apr;97( 4):489-93.

Nantel J; Brochu M; Prince F. Locomotor strategies in obese and non-obese children. Obesity (Silver Spring). 2006 Oct;14( 10):1789-94.

Dowling AM; Steele JR; Baur LA. Does obesity influence foot structure and plantar pressure patterns in prepubescent children?Int J Obes Relat Metab Disord. 2001 Jun;25( 6):845-52.

Shultz SP; Anner J; Hills AP. Paediatric obesity, physical activity and the musculoskeletal system. Obes Rev. 2009 Sep;10( 5):576-82. Epub 2009 May 12.

Sabharwal S. Blount disease. J Bone Joint Surg Am. 2009 Jul;91( 7):1758-76.

Scott AC; Kelly CH; Sullivan E. Body mass index as a prognostic factor in development of infantile Blount disease. J Pediatr Orthop. 2007 Dec;27( 8):921-5.

Sabharwal S; Zhao C; McClemens E. Correlation of body mass index and radiographic deformities in children with Blount disease. J Bone Joint Surg Am. 2007 Jun;89( 6):1275-83.

Schroerlucke S; Bertrand S; Clapp J; Bundy J; Gregg FO. Failure of Orthofix eight-Plate for the treatment of Blount disease. J Pediatr Orthop. 2009 Jan-Feb;29( 1):57-60.

McIntosh AL; Hanson CM; Rathjen KE. Treatment of adolescent tibia vara with hemiepiphysiodesis: risk factors for failure. J Bone Joint Surg Am. 2009 Dec;91( 12):2873-9.

de Sá Pinto AL; de Barros Holanda PM; Radu AS; Villares SM; Lima FR. Musculoskeletal findings in obese children. J Paediatr Child Health. 2006 Jun;42( 6):341-4.

Zhang AL; Exner GU; Wenger DR. Progressive genu valgum resulting from idiopathic lateral distal femoral physeal growth suppression in adolescents. J Pediatr Orthop. 2008 Oct-Nov;28( 7):752-6.

Denzer C; Weibel A; Muche R; Karges B; Sorgo W; Wabitsch M. Pubertal development in obese children and adolescents. Int J Obes (Lond). 2007 Oct;31( 10):1509-19. Epub 2007 Jul 24.

Vignolo M; Naselli A; Di Battista E; Mostert M; Aicardi G. Growth and development in simple obesity. Eur J Pediatr. 1988 Apr;147( 3):242-4.

Loder RT; Aronsson DD; Dobbs MB; Weinstein SL. Slipped capital femoral epiphysis. J Bone Joint Surg Am. 2000;82( 8):1170-88.

Poussa M; Schlenzka D; Yrjönen T. Body mass index and slipped capital femoral epiphysis. J Pediatr Orthop B. 2003 Nov;12( 6):369-71.

Azzopardi T; Sharma S; Bennet GC. Slipped capital femoral epiphysis in children aged less than 10 years. J Pediatr Orthop B. 2010 Jan;19( 1):13-8.

Benson EC; Miller M; Bosch P; Szalay EA. A new look at the incidence of slipped capital femoral epiphysis in New Mexico. J Pediatr Orthop. 2008 Jul-Aug;28( 5):529-33.

Lehmann CL; Arons RR; Loder RT; Vitale MG. The epidemiology of slipped capital femoral epiphysis: an update. J Pediatr Orthop. 2006 May-Jun;26( 3):286-90.

Bhatia NN; Pirpiris M; Otsuka NY. Body mass index in patients with slipped capital femoral epiphysis. J Pediatr Orthop. 2006 Mar-Apr;26( 2):197-9.

Brown CV; Neville AL; Salim A; Rhee P; Cologne K; Demetriades D. The impact of obesity on severely injured children and adolescents. J Pediatr Surg. 2006 Jan;41( 1):88-91; discussion 88–91.

Pollack KM; Xie D; Arbogast KB; Durbin DR. Body mass index and injury risk among US children 9-15 years old in motor vehicle crashes. Inj Prev. 2008 Dec;14( 6):366-71.

Pomerantz WJ; Timm NL; Gittelman MA. Injury patterns in obese versus nonobese children presenting to a pediatric emergency department. Pediatrics. 2010 Apr;125( 4):681-5. Epub 2010 Mar 1.

Goulding A; Jones IE; Taylor RW; Piggot JM; Taylor D. Dynamic and static tests of balance and postural sway in boys: effects of previous wrist bone fractures and high adiposity. Gait Posture. 2003 Apr;17( 2):136-41.

Leonard MB; Shults J; Wilson BA; Tershakovec AM; Zemel BS. Obesity during childhood and adolescence augments bone mass and bone dimensions. Am J Clin Nutr. 2004 Aug;80( 2):514-23.

Ryan LM; Teach SJ; Searcy K; Singer SA; Wood R; Wright JL; Chamberlain JM. Epidemiology of pediatric forearm fractures in Washington, DC. J Trauma. 2010 Oct;69( 4 Suppl):S200-5.

Skaggs DL; Loro ML; Pitukcheewanont P; Tolo V; Gilsanz V. Increased body weight and decreased radial cross-sectional dimensions in girls with forearm fractures. J Bone Miner Res. 2001 Jul;16( 7):1337-42.

Leet AI; Pichard CP; Ain MC. Surgical treatment of femoral fractures in obese children: does excessive body weight increase the rate of complications?J Bone Joint Surg Am. 2005 Dec;87( 12):2609-13.

Moroz LA; Launay F; Kocher MS; Newton PO; Frick SL; Sponseller PD; Flynn JM. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. J Bone Joint Surg Br. 2006 Oct;88( 10):1361-6.

Weiss JM; Choi P; Ghatan C; Skaggs DL; Kay RM. Complications with flexible nailing of femur fractures more than double with child obesity and weight >50 kg. J Child Orthop. 2009 Feb;3( 1):53-8. Epub 2008 Dec 10.

Garner MR; Bhat SB; Khujanazarov I; Flynn JM; Spiegel D. Fixation of length-stable femoral shaft fractures in heavier children: flexible nails vs rigid locked nails. J Pediatr Orthop. 2011 Jan-Feb;31( 1):11-6.

Mehlman CT; Bishai SK. Tibial nails for femoral shaft fractures in large adolescents with open femoral physes. J Trauma. 2007 Aug;63( 2):424-8.

O'Neill PJ; Karol LA; Shindle MK; Elerson EE; BrintzenhofeSzoc KM; Katz DE; Farmer KW; Sponseller PD. Decreased orthotic effectiveness in overweight patients with adolescent idiopathic scoliosis. J Bone Joint Surg Am. 2005 May;87( 5):1069-74.

Upasani VV; Caltoum C; Petcharaporn M; Bastrom T; Pawelek J; Marks M; Betz RR; Lenke LG; Newton PO. Does obesity affect surgical outcomes in adolescent idiopathic scoliosis?Spine (Phila Pa 1976). 2008 Feb 1;33( 3):295-300.

Arbabi S; Wahl WL; Hemmila MR; Kohoyda-Inglis C; Taheri PA; Wang SC. The cushion effect. J Trauma. 2003 Jun;54( 6):1090-3.

Brown CV; Neville AL; Rhee P; Salim A; Velmahos GC; Demetriades D. The impact of obesity on the outcomes of 1,153 critically injured blunt trauma patients. J Trauma. 2005 Nov;59( 5):1048-51; discussion 1051.

Finkelstein EA; Chen H; Prabhu M; Trogdon JG; Corso PS. The relationship between obesity and injuries among U.S. adults. Am J Health Promot. 2007 May-Jun;21( 5):460-8.

Bansal V; Conroy C; Lee J; Schwartz A; Tominaga G; Coimbra R. Is bigger better? The effect of obesity on pelvic fractures after side impact motor vehicle crashes. J Trauma. 2009 Oct;67( 4):709-14.

Maheshwari R; Mack CD; Kaufman RP; Francis DO; Bulger EM; Nork SE; Henley MB. Severity of injury and outcomes among obese trauma patients with fractures of the femur and tibia: a crash injury research and engineering network study. J Orthop Trauma. 2009 Oct;23( 9):634-9.

Strauss EJ; Frank JB; Walsh M; Koval KJ; Egol KA. Does obesity influence the outcome after the operative treatment of ankle fractures?J Bone Joint Surg Br. 2007 Jun;89( 6):794-8.

Abidi NA; Dhawan S; Gruen GS; Vogt MT; Conti SF. Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures. Foot Ankle Int. 1998 Dec;19( 12):856-61.

Carlson DA; Simmons J; Sando W; Weber T; Clements B. Morel-Lavalée lesions treated with debridement and meticulous dead space closure: surgical technique. J Orthop Trauma. 2007 Feb;21( 2):140-4.

Peltola EK; Lindahl J; Hietaranta H; Koskinen SK. Knee dislocation in overweight patients. AJR Am J Roentgenol. 2009 Jan;192( 1):101-6.

Hagino RT; DeCaprio JD; Valentine RJ; Clagett GP. Spontaneous popliteal vascular injury in the morbidly obese. J Vasc Surg. 1998 Sep;28( 3):458-62; discussion 462–3.

Ducy P; Amling M; Takeda S; Priemel M; Schilling AF; Beil FT; Shen J; Vinson C; Rueger JM; Karsenty G. Leptin inhibits bone formation through a hypothalamic relay: a central control of bone mass. Cell. 2000 Jan 21;100( 2):197-207.

Einhorn TA. Brain, bone, and body mass: fat is beautiful again. J Bone Joint Surg Am. 2001 Dec;83-A( 12):1782.

Haberland M; Schilling AF; Rueger JM; Amling M. Brain and bone: central regulation of bone mass. A new paradigm in skeletal biology. J Bone Joint Surg Am. 2001 Dec;83-A( 12):1871-6.

Sato M; Takeda N; Sarui H; Takami R; Takami K; Hayashi M; Sasaki A; Kawachi S; Yoshino K; Yasuda K. Association between serum leptin concentrations and bone mineral density, and biochemical markers of bone turnover in adult men. J Clin Endocrinol Metab. 2001 Nov;86( 11):5273-6.

Templeton DL; Kelly AS; Steinberger J; Dengel DR. Lower relative bone mineral content in obese adolescents: role of non-weight bearing exercise. Pediatr Exerc Sci. 2010 Nov;22( 4):557-68.

Beck TJ; Petit MA; Wu G; LeBoff MS; Cauley JA; Chen Z. Does obesity really make the femur stronger? BMD, geometry, and fracture incidence in the women's health initiative-observational study. J Bone Miner Res. 2009 Aug;24( 8):1369-79.

Maffulli N; Dougall TW; Brown MT; Golden MH. Nutritional differences in patients with proximal femoral fractures. Age Ageing. 1999 Sep;28( 5):458-62.

Campbell WW; Tang M. Protein intake, weight loss, and bone mineral density in postmenopausal women. J Gerontol A Biol Sci Med Sci. 2010 Oct;65( 10):1115-22. Epub 2010 Jul 6.

Streubel PN; Gardner MJ; Ricci WM. Management of femur shaft fractures in obese patients. Orthop Clin North Am. 2011 Jan;42( 1):21-35, v. Epub 2010 Oct 8.

Handolin LE; Hiltunen OJ. Peroperative difficulties in fluoroscopy of the femoral head in massive obese patient: enhanced visualization by intra-articular contrast agent. Arch Orthop Trauma Surg. 2006 Sep;126( 7):498-9. Epub 2006 Jun 21.

McKee MD; Waddell JP. Intramedullary nailing of femoral fractures in morbidly obese patients. J Trauma. 1994 Feb;36( 2):208-10.

100

Tucker MC; Schwappach JR; Leighton RK; Coupe K; Ricci WM. Results of femoral intramedullary nailing in patients who are obese versus those who are not obese: a prospective multicenter comparison study. J Orthop Trauma. 2007 Sep;21( 8):523-9.

101

Ostrum RF. A greater trochanteric insertion site for femoral intramedullary nailing in lipomatous patients. Orthopedics. 1996 Apr;19( 4):337-40.

102

Böstman OM. Body-weight related to loss of reduction of fractures of the distal tibia and ankle. J Bone Joint Surg Br. 1995 Jan;77( 1):101-3.

103

Karunakar MA; Shah SN; Jerabek S. Body mass index as a predictor of complications after operative treatment of acetabular fractures. J Bone Joint Surg Am. 2005 Jul;87( 7):1498-502.

104

Porter SE; Russell GV; Dews RC; Qin Z; Woodall J Jr; Graves ML. Complications of acetabular fracture surgery in morbidly obese patients. J Orthop Trauma. 2008 Oct;22( 9):589-94.

105

Sems SA; Johnson M; Cole PA; Byrd CT; Templeman DC; Minnesota Orthopaedic Trauma Group. Elevated body mass index increases early complications of surgical treatment of pelvic ring injuries. J Orthop Trauma. 2010 May;24( 5):309-14.

106

Felson DT. Does excess weight cause osteoarthritis and, if so, why?Ann Rheum Dis. 1996 Sep;55( 9):668-70.

107

Flugsrud GB; Nordsletten L; Espehaug B; Havelin LI; Engeland A; Meyer HE. The impact of body mass index on later total hip arthroplasty for primary osteoarthritis: a cohort study in 1.2 million persons. Arthritis Rheum. 2006 Mar;54( 3):802-7.

108

Grotle M; Hagen KB; Natvig B; Dahl FA; Kvien TK. Obesity and osteoarthritis in knee, hip and/or hand: an epidemiological study in the general population with 10 years follow-up. BMC Musculoskelet Disord. 2008 Oct 2;9:132.

109

Leach RE; Baumgard S; Broom J. Obesity: its relationship to osteoarthritis of the knee. Clin Orthop Relat Res. 1973 Jun;( 93):271-3.

110

Lievense AM; Bierma-Zeinstra SM; Verhagen AP; van Baar ME; Verhaar JA; Koes BW. Influence of obesity on the development of osteoarthritis of the hip: a systematic review. Rheumatology (Oxford). 2002 Oct;41( 10):1155-62.

111

Lievense AM; Reijman M; Pols HA; Bierma-Zeinstra SM. Obesity and hip osteoarthritis. Am J Med. 2003 Sep;115( 4):329; author reply 329–30.

112

Reijman M; Pols HA; Bergink AP; Hazes JM; Belo JN; Lievense AM; Bierma-Zeinstra SM. Body mass index associated with onset and progression of osteoarthritis of the knee but not of the hip: the Rotterdam Study. Ann Rheum Dis. 2007 Feb;66( 2):158-62. Epub 2006 Jul 12.

113

Bourne R; Mukhi S; Zhu N; Keresteci M; Marin M. Role of obesity on the risk for total hip or knee arthroplasty. Clin Orthop Relat Res. 2007 Dec;465:185-8.

114

Changulani M; Kalairajah Y; Peel T; Field RE. The relationship between obesity and the age at which hip and knee replacement is undertaken. J Bone Joint Surg Br. 2008 Mar;90( 3):360-3.

115

Muthuri SG; Hui M; Doherty M; Zhang W. What if we prevent obesity? Risk reduction in knee osteoarthritis estimated through a meta-analysis of observational studies. Arthritis Care Res (Hoboken). 2011 Jul;63( 7):982-90.

116

Andrew JG; Palan J; Kurup HV; Gibson P; Murray DW; Beard DJ. Obesity in total hip replacement. J Bone Joint Surg Br. 2008 Apr;90( 4):424-9.

117

Perka C; Labs K; Muschik M; Buttgereit F. The influence of obesity on perioperative morbidity and mortality in revision total hip arthroplasty. Arch Orthop Trauma Surg. 2000;120( 5-6):267-71.

118

Namba RS; Paxton L; Fithian DC; Stone ML. Obesity and perioperative morbidity in total hip and total knee arthroplasty patients. J Arthroplasty. 2005 Oct;20( 7 Suppl 3):46-50.

119

Sadr Azodi O; Bellocco R; Eriksson K; Adami J. The impact of tobacco use and body mass index on the length of stay in hospital and the risk of post-operative complications among patients undergoing total hip replacement. J Bone Joint Surg Br. 2006 Oct;88( 10):1316-20.

120

Lübbeke A; Moons KG; Garavaglia G; Hoffmeyer P. Outcomes of obese and nonobese patients undergoing revision total hip arthroplasty. Arthritis Rheum. 2008 May 15;59( 5):738-45.

121

Søballe K; Christensen F; Luxhøj T. Hip replacement in obese patients. Acta Orthop Scand. 1987 Jun;58( 3):223-5.

122

Flugsrud GB; Nordsletten L; Espehaug B; Havelin LI; Meyer HE. The effect of middle-age body weight and physical activity on the risk of early revision hip arthroplasty: a cohort study of 1,535 individuals. Acta Orthop. 2007 Feb;78( 1):99-107.

123

Malinzak RA; Ritter MA; Berend ME; Meding JB; Olberding EM; Davis KE. Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates. J Arthroplasty. 2009 Sep;24( 6 Suppl):84-8. Epub 2009 Jul 15.

124

Röder C; Bach B; Berry DJ; Eggli S; Langenhahn R; Busato A. Obesity, age, sex, diagnosis, and fixation mode differently affect early cup failure in total hip arthroplasty: a matched case-control study of 4420 patients. J Bone Joint Surg Am. 2010 Aug 18;92( 10):1954-63.

125

Dowsey MM; Choong PF. Obese diabetic patients are at substantial risk for deep infection after primary TKA. Clin Orthop Relat Res. 2009 Jun;467( 6):1577-81. Epub 2008 Oct 8.

126

Krushell RJ; Fingeroth RJ. Primary total knee arthroplasty in morbidly obese patients: a 5- to 14-year follow-up study. J Arthroplasty. 2007 Sep;22( 6 Suppl 2):77-80. Epub 2007 Jul 26.

127

Dewan A; Bertolusso R; Karastinos A; Conditt M; Noble PC; Parsley BS. Implant durability and knee function after total knee arthroplasty in the morbidly obese patient. J Arthroplasty. 2009 Sep;24( 6 Suppl):89-94, 94.e1-3. Epub 2009 Jul 2.

128

Stern SH; Insall JN. Total knee arthroplasty in obese patients. J Bone Joint Surg Am. 1990 Oct;72( 9):1400-4.

129

Naal FD; Neuerburg C; Salzmann GM; Kriner M; von Knoch F; Preiss S; Drobny T; Munzinger U. Association of body mass index and clinical outcome 2 years after unicompartmental knee arthroplasty. Arch Orthop Trauma Surg. 2009 Apr;129( 4):463-8. Epub 2008 Apr 15.

130

Berend KR; Lombardi AV Jr; Mallory TH; Adams JB; Groseth KL. Early failure of minimally invasive unicompartmental knee arthroplasty is associated with obesity. Clin Orthop Relat Res. 2005 Nov;440:60-6.

131

Coventry MB; Ilstrup DM; Wallrichs SL. Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J Bone Joint Surg Am. 1993 Feb;75( 2):196-201.

132

Spahn G; Kirschbaum S; Kahl E. Factors that influence high tibial osteotomy results in patients with medial gonarthritis: a score to predict the results. Osteoarthritis Cartilage. 2006 Feb;14( 2):190-5. Epub 2005 Nov 4.

133

Amin AK; Clayton RA; Patton JT; Gaston M; Cook RE; Brenkel IJ. Total knee replacement in morbidly obese patients. Results of a prospective, matched study. J Bone Joint Surg Br. 2006 Oct;88( 10):1321-6.

134

Foran JR; Mont MA; Etienne G; Jones LC; Hungerford DS. The outcome of total knee arthroplasty in obese patients. J Bone Joint Surg Am. 2004 Aug;86-A( 8):1609-15.

135

Jackson MP; Sexton SA; Walter WL; Walter WK; Zicat BA. The impact of obesity on the mid-term outcome of cementless total knee replacement. J Bone Joint Surg Br. 2009 Aug;91( 8):1044-8.

136

Singh JA; O'Byrne M; Harmsen S; Lewallen D. Predictors of moderate-severe functional limitation after primary Total Knee Arthroplasty (TKA): 4701 TKAs at 2-years and 2935 TKAs at 5-years. Osteoarthritis Cartilage. 2010 Apr;18( 4):515-21. Epub 2009 Dec 21.

137

Dowsey MM; Liew D; Stoney JD; Choong PF. The impact of pre-operative obesity on weight change and outcome in total knee replacement: a prospective study of 529 consecutive patients. J Bone Joint Surg Br. 2010 Apr;92( 4):513-20.

138

Lachiewicz AM; Lachiewicz PF. Weight and activity change in overweight and obese patients after primary total knee arthroplasty. J Arthroplasty. 2008 Jan;23( 1):33-40.

139

Zeni JA Jr; Snyder-Mackler L. Most patients gain weight in the 2 years after total knee arthroplasty: comparison to a healthy control group. Osteoarthritis Cartilage. 2010 Apr;18( 4):510-4. Epub 2009 Dec 21.

140

Heisel C; Silva M; dela Rosa MA; Schmalzried TP. The effects of lower-extremity total joint replacement for arthritis on obesity. Orthopedics. 2005 Feb;28( 2):157-9.

141

Middleton FR; Boardman DR. Total hip arthroplasty does not aid weight loss. Ann R Coll Surg Engl. 2007 Apr;89( 3):288-91.

142

Woolf VJ; Charnley GJ; Goddard NJ. Weight changes after total hip arthroplasty. J Arthroplasty. 1994 Aug;9( 4):389-91.

143

Hitt HC; McMillen RC; Thornton-Neaves T; Koch K; Cosby AG. Comorbidity of obesity and pain in a general population: results from the Southern Pain Prevalence Study. J Pain. 2007 May;8( 5):430-6. Epub 2007 Mar 6.

144

Samartzis D; Karppinen J; Mok F; Fong DY; Luk KD; Cheung KM. A population-based study of juvenile disc degeneration and its association with overweight and obesity, low back pain, and diminished functional status. J Bone Joint Surg Am. 2011 Apr 6;93( 7):662-70.

145

Leboeuf-Yde C. Body weight and low back pain. A systematic literature review of 56 journal articles reporting on 65 epidemiologic studies. Spine (Phila Pa 1976). 2000 Jan 15;25( 2):226-37.

146

Chou R; Shekelle P. Will this patient develop persistent disabling low back pain?JAMA. 2010 Apr 7;303( 13):1295-302.

147

Hadler NM. Editorial: the semiotics of backache. Spine (Phila Pa 1976). 2004 Jun 15;29( 12):1289.

148

Jarvik JG; Hollingworth W; Heagerty PJ; Haynor DR; Boyko EJ; Deyo RA. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine (Phila Pa 1976). 2005 Jul 1;30( 13):1541-8; discussion 1549.

149

Dersh J; Gatchel RJ; Mayer T; Polatin P; Temple OR. Prevalence of psychiatric disorders in patients with chronic disabling occupational spinal disorders. Spine (Phila Pa 1976). 2006 May 1;31( 10):1156-62.

150

Blankmeyer BL; Smylie KD; Price DC; Costello RM; McFee AS; Fuller DS. A replicated five cluster MMPI typology of morbidly obese female candidates for gastric bypass. Int J Obes. 1990 Mar;14( 3):235-47.

151

Wickramasekera I; Price DC. Morbid obesity, absorption, neuroticism, and the high risk model of threat perception. Am J Clin Hypn. 1997 Apr;39( 4):291-301.

152

Videman T; Gibbons LE; Kaprio J; Battié MC. Challenging the cumulative injury model: positive effects of greater body mass on disc degeneration. Spine J. 2010 Jan;10( 1):26-31. Epub 2009 Nov 18.

153

Böstman OM. Body mass index and height in patients requiring surgery for lumbar intervertebral disc herniation. Spine (Phila Pa 1976). 1993 Jun 1;18( 7):851-4.

154

Liuke M; Solovieva S; Lamminen A; Luoma K; Leino-Arjas P; Luukkonen R; Riihimäki H. Disc degeneration of the lumbar spine in relation to overweight. Int J Obes (Lond). 2005 Aug;29( 8):903-8.

155

Garcia RM; Messerschmitt PJ; Furey CG; Bohlman HH; Cassinelli EH. Weight loss in overweight and obese patients following successful lumbar decompression. J Bone Joint Surg Am. 2008 Apr;90( 4):742-7.

156

Andreshak TG; An HS; Hall J; Stein B. Lumbar spine surgery in the obese patient. J Spinal Disord. 1997 Oct;10( 5):376-9.

157

Gepstein R; Shabat S; Arinzon ZH; Berner Y; Catz A; Folman Y. Does obesity affect the results of lumbar decompressive spinal surgery in the elderly?Clin Orthop Relat Res. 2004 Sep;( 426):138-44.

158

Peng CW; Bendo JA; Goldstein JA; Nalbandian MM. Perioperative outcomes of anterior lumbar surgery in obese versus non-obese patients. Spine J. 2009 Sep;9( 9):715-20. Epub 2009 Jun 13.

159

Park P; Upadhyaya C; Garton HJ; Foley KT. The impact of minimally invasive spine surgery on perioperative complications in overweight or obese patients. Neurosurgery. 2008 Mar;62( 3):693-9; discussion 693–9.

160

Rodgers WB; Cox CS; Gerber EJ. Early complications of extreme lateral interbody fusion in the obese. J Spinal Disord Tech. 2010 Aug;23( 6):393-7.

161

Rosen DS; Ferguson SD; Ogden AT; Huo D; Fessler RG. Obesity and self-reported outcome after minimally invasive lumbar spinal fusion surgery. Neurosurgery. 2008 Nov;63( 5):956-60; discussion 960.

162

Berg EE. Knee joint arthroscopy in the morbidly obese. Arthroscopy. 1998 Apr;14( 3):321-4.

163

Wendelboe AM; Hegmann KT; Gren LH; Alder SC; White GL Jr; Lyon JL. Associations between body-mass index and surgery for rotator cuff tendinitis. J Bone Joint Surg Am. 2004 Apr;86-A( 4):743-7.

164

Spahn G; Mückley T; Kahl E; Hofmann GO. Factors affecting the outcome of arthroscopy in medial-compartment osteoarthritis of the knee. Arthroscopy. 2006 Nov;22( 11):1233-40.

165

Harrison MM; Morrell J; Hopman WM. Influence of obesity on outcome after knee arthroscopy. Arthroscopy. 2004 Sep;20( 7):691-5.

166

Schippinger G; Wirnsberger GH; Obernosterer A; Babinski K. Thromboembolic complications after arthroscopic knee surgery. Incidence and risk factors in 101 patients. Acta Orthop Scand. 1998 Apr;69( 2):144-6.

167

Dixon JB; Reuben Y; Halket C; O'Brien PE. Shoulder pain is a common problem following laparoscopic adjustable gastric band surgery. Obes Surg. 2005 Sep;15( 8):1111-7.

168

Roquelaure Y; Ha C; Rouillon C; Fouquet N; Leclerc A; Descatha A; Touranchet A; Goldberg M; Imbernon E; Members of Occupational Health Services of the Pays de la Loire Region. Risk factors for upper-extremity musculoskeletal disorders in the working population. Arthritis Rheum. 2009 Oct 15;61( 10):1425-34.

169

Geoghegan JM; Clark DI; Bainbridge LC; Smith C; Hubbard R. Risk factors in carpal tunnel syndrome. J Hand Surg Br. 2004 Aug;29( 4):315-20.

170

Kouyoumdjian JA; Morita MD; Rocha PR; Miranda RC; Gouveia GM. Body mass index and carpal tunnel syndrome. Arq Neuropsiquiatr. 2000 Jun;58( 2A):252-6.

171

Stallings SP; Kasdan ML; Soergel TM; Corwin HM. A case-control study of obesity as a risk factor for carpal tunnel syndrome in a population of 600 patients presenting for independent medical examination. J Hand Surg Am. 1997 Mar;22( 2):211-5.

172

Kurt S; Kisacik B; Kaplan Y; Yildirim B; Etikan I; Karaer H. Obesity and carpal tunnel syndrome: is there a causal relationship?Eur Neurol. 2008;59( 5):253-7. Epub 2008 Feb 8.

173

Linberg CJ; Sperling JW; Schleck CD; Cofield RH. Shoulder arthroplasty in morbidly obese patients. J Shoulder Elbow Surg. 2009 Nov-Dec;18( 6):903-6. Epub 2009 May 22.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution, have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Topics

obesity

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Impact of Obesity on Orthopaedics'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Impact of Obesity on Orthopaedics'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Sanjeev Sabharwal, Michael Z. Root; Impact of Obesity on Orthopaedics. The Journal of Bone & Joint Surgery. 2012 Jun;94(11):1045-1052.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment