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The Journal of Arthroplasty Vol. 20 No.

7 2005

Does Body Mass Index Affect The Early Outcome of


Primary Total Hip Arthroplasty?

Matthew Moran, MRCSEd, P. Walmsley, MRCSEd,


A. Gray, MRCS, and I.J. Brenkel, FRCS

Abstract: There is little evidence describing the influence of body mass index on the
outcome of total hip arthroplasty (THA). Eight hundred patients undergoing primary
cemented THA were followed for a minimum of 18 months. The Harris Hip Score
(HHS) and Short Form 36 were recorded preoperatively and at 6 and 18 months
postoperatively. In addition, other significant events were noted, namely death,
dislocation, reoperation, superficial and deep infection, and blood loss. Multiple
regression analysis was performed to identify whether body mass index (BMI) was
an independently significant predictor of the outcome of THA. No relationship was
seen between the BMI of an individual and the development of any of the
complications noted. The HHS was seen to increase dramatically postoperatively in
all patients. Body mass index did predict for a lower HHS at 6 and 18 months. This
effect was small when compared with the overall improvements in these scores.
There was no influence on the Short Form 36 component scores. On the basis of this
study, we can find no justification for withholding THA solely on the grounds of BMI.
Key words: body mass index, total hip arthroplasty, Harris Hip Score.
n 2005 Elsevier Inc. All rights reserved.

Total hip arthroplasty (THA) provides long-lasting There are concerns that an increasing body mass
improvement in quality of life and reduction in index (BMI) negatively impacts on the outcome
pain for patients with disabling arthritis. However, of THA, and surgeons may decline to operate
there are groups of patients that have been shown on the obese for fear of the complications that
to have outcomes that are poorer than the general may follow. Possible areas of increased complica-
population. A poorer outcome may be affected by tions include increased length of operative time
the underlying diagnosis, for example, femoral [4,5], venous thromboembolism [6], superficial
neck fracture [1]; by the choice of implant, for and deep wound infection [7], increased blood loss
example, the Capital THA [2]; or by the surgeon, [8,9], and aseptic loosening due to increased
for example, infrequently performed THA [3]. loading through the THA.
Despite the theoretical increased rate of compli-
cations, there is evidence to show that the symp-
tomatic relief after THA is as effective in the obese as
From the Department of Orthopaedic Surgery, Queen Margaret in thinner patients [10,11]. In 2000, the UK National
Hospital, Dunfermline, Fife, UK. Audit Office criticized orthopedic surgeons for the
Submitted November 18, 2003; accepted February 3, 2005.
No benefits or funds were received in support of the study. use of bvarying criteria for weight above which they
Reprint requests: Matthew Moran, MRCSEd, 19 Plewlands may not operateQ [12]. It is important that decisions
Gardens, EH10 5JS Edinburgh, UK. about the suitability of patients for surgery are made
n 2005 Elsevier Inc. All rights reserved.
0883-5403/05/1906-0004$30.00/0 on good evidence. We set out to examine the early
doi:10.1016/j.arth.2005.02.008 complication rate in obese patients after THA.

866
Does Body Mass Index Affect The Early Outcome of Primary THA? ! Moran et al 867

Methods 20 to 24.9 kg/m2 reflecting ideal weight, 25 to


29.9 kg/m2 reflecting overweight, 30 to 39.9 kg/m2
Patients reflecting obesity, and 40 kg/m2 or greater reflect-
Eight hundred consecutive patients undergoing ing morbid obesity.
Charnley primary THA (De Puy International,
Statistics
Leeds, UK) were investigated prospectively. The
patients were under the care of 6 consultant The SPSSv9.0 (SPSS Inc, Chicago, Ill) computer
orthopedic surgeons at a single hospital. The joint package was used to analyze results.
arthroplasties were carried out between January The paired Student t test was used to detect
1998 and November 2000. A standard anterolateral changes in the HHS before and after surgery.
approach to the hip was used by all surgeons. Data Univariate analysis was performed using v 2 tests,
from the patients were collected by a specialist 2-sample t tests, or Pearson’s correlation coefficient
nurse and stored on a local database. to identify significant predictors of the measured
The following events were recorded: length of outcomes. The predictors were operating surgeon,
stay in the hospital, death, dislocation, reoperation, age, sex, side of surgery, length of stay in hospital,
superficial and deep wound infection, blood loss, concomitant medical problems (see above), blood
and transfusion requirement. Superficial wound loss, transfused units of blood, and preoperative
infection was diagnosed in the presence of dis- HHS. The outcomes were reoperation, death,
charge from the surgical wound or spreading dislocation, deep and superficial infection, and
cellulitis and a positive microbiological culture of HHS. Once possibly significant predictors of out-
a microorganism known to be implicated in causing come had been identified by this method, stepwise
wound infection. Deep infection was suspected on multiple regression analysis was carried out to
clinical and radiological grounds but only diag- identify any predictors that would independently
nosed after the growth of putative microorganisms alter outcome. Multiple logistic regression was
from specimens taken at reoperation. Blood loss performed for binary outcomes (eg, death) and
was calculated from perioperative losses (suction multiple regression linear analysis for continuous
and swabs) plus postoperative drainage. variables (eg, HHS).
Concomitant medical problems were recorded
under the headings: smoker, cancer, atherosclero-
sis, cardiac, diabetes mellitus, osteoporosis, and
Results
thromboembolism.
Eight hundred total hip arthroplasties were
Outcome Measures
carried out in 759 patients. Sixty-one percent were
The Harris Hip Score (HHS) and Short Form 36 female and 39% male. Four hundred fifty-nine
(SF-36) were the primary outcome measures used THAs were left sided. The mean age was 68 years.
[13,14]. The HHS combines scores for pain, func- Of the 800 THA episodes, all completed a preoper-
tion, activities, absence of deformity, and range of ative HHS and SF-36. Seven hundred seventy-four
motion to produce an overall score out of 100 completed an HHS/SF-36 at 6 months and 687 com-
(0, bad; 100, good). The score is mostly determined pleted the scores at 18 months. The mean BMI was
by feedback from the patient and weighted strongly
toward pain and function. It has been shown to 350
be a reliable indicator of patient function and pain 300
Number of patients

before and after THA [15]. The SF-36 is a widely


250
used measure of patient health that is not specific
to one disease. It is a good measure of patient 200
symptoms after THA [16]. Both scores were 150
completed 7 days preoperatively as well as 6 and
100
18 months postoperatively.
Body mass index was taken as a marker of 50
obesity. It is calculated from the weight (kilograms) 0
divided by the square of the height (meters). The <20 20-24.9 25-29.9 30-39.9 40+
BMI is widely recognized as a tool for the simple Body Mass Index
calculation of obesity. It corrects the weight of the
patient for their height. A score is generated with Fig. 1. Distribution of patients by obesity category.
868 The Journal of Arthroplasty Vol. 20 No. 7 October 2005

27.8 kg/m2 (range, 17-49) with a standard devia- multiple regression coefficient b was noted. At
tion of 5 (Fig. 1). There was no difference in the 6 months, b = .25 (95% confidence intervals
BMI of patients defaulting to follow-up and those [CIs], .05 to .45), and at 18 months, b = .35
who completed follow-up ( P = .32). On average, (95% CIs, .15 to .55). That is, for every 1 point
0.7 units of blood were transfused and mean blood increase in BMI, the HHS dropped on average by
loss was 537 mL (SD, 296 mL). The mean length of 0.25 or 0.35. The other predictors with a significant
stay was 10 days. individual influence on the postoperative HHS were
Thirty-three patients had died by the 18-month length of stay, previous thromboembolism or coro-
follow-up (39 hips). There had been 13 dislocations nary heart disease, drop in hemoglobin at 24 hours,
(at an average of 15 weeks). Fifteen patients and preoperative HHS. By far, the most significant
underwent a further operation (not including of these is the preoperative HHS (see Fig. 2).
reduction of a dislocated joint). Three revision Body mass index was not a significant predictor
operations, 11 debridements, and 1 posterior lip for any of the SF-36 component scores.
augment were carried out within the first 18 months.
Seven deep infections and 56 superficial wound
infections had occurred by 18 months. Discussion
The mean preoperative HHS was 42. This im-
proved to 81 at 6 months and 85 at 18 months The HHS improved considerably after surgery.
postoperatively. There was a significant improve- The hip score is weighted toward the patient’s
ment in the HHS scores at 6 and 18 months when assessment of pain, function, and activity (91 of
compared with the preoperative score ( P b .0001). 100 points), with lesser emphasis on surgeon-
Univariate analysis suggested that BMI might determined measures such as range of motion
predict for increased rates of superficial infection and absence of deformity (9 of 100). Ultimately,
and a lower HHS at 6 and 18 months postopera- the patients’ view on the outcome of surgery is
tively (all P b .05). However, once multiple logistic probably the most important, and the HHS is a good
regression was carried out, BMI was not found to measure of patient symptoms.
be a significant independent predictor of superficial Body mass index independently predicted for
wound infection. a lower HHS at 6 and 18 months. However, its
When multiple regression analysis was per- individual effect, whereas significant statistically,
formed for the HHS at 6 and 18 months, taking was small. If we take a change in BMI of 20 points
into account other significant predictors, BMI was (the difference between being underweight and
still found to be significant ( P = .02 at 6 months and morbidly obese), we estimate that it will only
P b .001 at 18 months). To calculate the individual produce on average a lowering in the HHS of 5.0 at
effect a change in BMI might have on HHS, the 6 months and 7.0 at 18 months. These changes are
small given that the mean improvement in the HHS
at 18 months is 43. None of the 9 component scores
HHS 6 HHS 18
of the SF-36 were predicted by BMI.
30
We saw no relationship between BMI and early
25
failure of THA. Although the obese may put
% variance explained

increased loads through their joint arthroplasty,


20 there is evidence that the more obese a patient, the
less active they are. Hence, the increased weight is
15 balanced by decreased cycles of loading [17].
In a paper comparing 41 obese and 125 nonobese
10 patients, Soballe et al [9] noted increased blood loss
in the obese group. In a series of 80 patients,
5
Bowditch and Vilar [8] also noted increased blood
0 loss in obese patients when compared to those
Baseline Length stay Comorbidity Drop Hb BMI of ideal weight. Multiple regression analysis is a
HHS sophisticated tool that allows for the correction of
Fig. 2. The relative contributions (percentage of variance other variables in assessing the individual influence
explained) of predictors to the HHS at 6 and 18 months. of BMI. Even with the large numbers in our study,
Comorbidity indicates coronary and thromboembolism; once other factors such as comorbidity are taken into
Hb, hemoglobin; HHS 6, Harris Hip Score at 6 months; account, we did not find that BMI per se increased
HHS 18, Harris Hip Score at 18 months. measured blood loss or transfusion requirement.
Does Body Mass Index Affect The Early Outcome of Primary THA? ! Moran et al 869

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