Вы находитесь на странице: 1из 7

Obesity Surgery (2018) 28:13951401

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

28:1395 – 1401 https://doi.org/10.1007/s11695-017-3034-6 ORIGINAL CONTRIBUTIONS Bariatric Surgery and Time to Total

ORIGINAL CONTRIBUTIONS

ORIGINAL CONTRIBUTIONS
ORIGINAL CONTRIBUTIONS Bariatric Surgery and Time to Total Joint Arthroplasty: Does
ORIGINAL CONTRIBUTIONS Bariatric Surgery and Time to Total Joint Arthroplasty: Does

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 patients 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

Investigation performed at NYU Langone Medical Center in New York, New York. This study was determined to be exempt from review by the institutional review board.

* Jessica Hooper jessica.hooper@nyumc.org

1 Department of Orthopedic Surgery, New York University Hospital for Joint Diseases, 301 E 17th Street, Suite 1402, New York, NY 10003, USA

2 Department of Biostatistics, New York University Langone Medical Center, 550 First Avenue, New York, NY 10016, USA

3 Department of Surgery, New York University Langone Medical Center, 550 First Avenue, New York, NY 10016, USA

4 Department of Population Health, New York University Langone Medical Center, 550 First Avenue, New York, NY 10016, USA

Background

The prevalence of obesity in adults in the USA has increased by 4.9% over the past decade [1, 2]. Obesity contributes to many chronic medical conditions such as obstructive sleep apnea, hypertension, hyperlipidemia, diabetes mellitus, and cardiovascular disease [3]. In addition to the increased preva- lence of medical comorbidities in the obese population, these patients are also more likely to have metabolic derangements and have a higher prevalence of malnourishment compared to non-obese patients [3]. Obesity has also been identified as a risk factor for the development of osteoarthritis; increased loads at the hip, and especially at the knee joints, during activities of daily living are directly related to increased weight [4, 5]. Obese patients consequently develop end-stage arthropathy more quickly

directly related to increased weight [ 4 , 5 ]. Obese patients consequently develop end-stage arthropathy

1396

OBES SURG (2018) 28:13951401

than their non-obese peers, and are often younger with more medical comorbidities when they are considered for total joint arthroplasty (TJA). Due to the increased technical difficulty of the operation, malnourished status, and overall poorer health, obesity is associated with hi gher complication rates and readmissions following TJA [ 6 , 7 ]. A body mass index (BMI) > 40 kg/m 2 has been observed as a threshold at which complications and revision rates increase among TJA patients [8]. The super obese (BMI > 50 kg/m 2 ) patient population has been reported to have an even higher risk for perioperative complications [9]. Bariatric surgery is often recommended prior to TJA for morbidly obese patients with end-stage arthropathy. Bariatric procedures have proven to be a more effective means of weight loss than nonsurgical interventions in morbidly obese patients [10], and can help induce partial or complete remis- sion of obesity-related comorbidities such as type 2 diabetes mellitus, hypertension, and dyslipidemia [10]. Previous stud- ies have examined the effect of bariatric surgery prior to TJA on perioperative complications and postoperative outcomes, but the results remain inconclusive [1115]. It is not clear from the published evidence how time from bariatric surgery to TJA surgery affects the TJA risk profile of an obese patient. We sought to evaluate how the time (months) from bariatric surgery to TJA surgery affected the rate of peri- operative TJA complications and readmissions. We hypothe- sized that increasing the time between bariatric surgery to TJA surgery would allow patients to lose weight and adjust to the metabolic changes that occur after bariatric surgery, leading to lower complication and readmission rates following TJA.

Methods

Data Source

We utilized the Healthcare Cost and Utilization Project (HCUP) California State Inpatient Database (SID) to identify patients that underwent total joint arthroplasty (TJA) follow- ing bariatric surgery between 2007 and 2011. The HCUP SID is a population-based dataset encompassing all hospital dis- charge records from the state of California. ICD-9-CM diag- nosis and procedure codes were used to identify bariatric sur- gery, total hip arthroplasty (THA), total knee arthroplasty (TKA), and select complications following THA/TKA (Table 3 in Appendix). These data are de-identified and are exempt from IRB review.

Cohort Selection

Patients undergoing bariatric surgery followed by a total joint replacement (THA or TKA) were identified. If a patient had more than one TJA following bariatric surgery, then only the

more than one TJA following bariatric surgery, then only the first TJA was selected. Patients who

first TJA was selected. Patients who underwent a TJA prior to bariatric surgery were excluded (n = 853). To confirm that no TJA occurred in the year prior to bariatric surgery, we allowed for a 1-year lookback from bariatric surgery discharge to eval- uate whether TJA occurred, with observation starting in 2006 for the 2007 bariatric surgery patients. We excluded patients with more than one bariatric surgery between 2006 and 2011 and patients who underwent TJA for fracture, such as femoral neck fractures. Our final sample included 1347 patients. The primary outcomes were 90-day complications and all- cause 90-day readmission following the TJA. A complication was assessed at the TJA surgical admission and at any read- mission within 90 days, and included one or more of the following based on ICD-9-CM codes (Table 1): pulmonary embolism, deep vein thrombosis, acute myocardial infarction,

Table 1 Characteristics of patients undergoing bariatric surgery followed by total joint arthroplasty in California (n = 1347), 20072011

Characteristics

Total hip arthroplasty (n = 330) n (%)

Total knee arthroplasty (n = 1017) n (%)

90-day complications

No

181 (54.8)

687 (67.6)

Yes

149 (45.2)

330 (32.4)

90-day all-cause readmission

 

No readmissions

256 (77.6)

842 (82.8)

Readmission

74 (22.4)

175 (17.2)

Months between bariatric surgery and TJA

06 months

61 (18.5)

98 (9.6)

712 months

85 (25.8)

200 (19.7)

1318 months

53 (16.1)

197 (19.4)

1924 months

43 (13.0)

144 (14.2)

> 24 months

88

(26.7)

378 (37.2)

Age (years; at bariatric surgery)

< 50 years

85

(25.8)

185 (18.2)

5059 years

153 (46.4)

478 (47.0)

6069 years

80 (24.2)

315 (31.0)

70+ years

12 (3.6)

39 (3.8)

Sex

Male

101 (30.6)

240 (23.6)

Female

229 (69.4)

777 (76.4)

Race

White

279 (84.5)

836 (82.2)

Black

28 (8.5)

89 (8.8)

Other/unknown

23 (7.0)

92 (9.0)

Ethnicity

Non-Hispanic

300 (90.9)

881 (86.6)

Hispanic

30 (9.1)

136 (13.4)

Insurance

All other insurance 309 (93.6)

Ever Medicaid

21 (6.4)

967 (95.1)

50 (4.9)

OBES SURG (2018) 28:13951401

1397

respiratory failure, cerebrovascular event, urinary tract infec- tion, blood transfusion, cardiac complications, peripheral vas- cular disease, respiratory complications, gastrointestinal com- plications, gastrointestinal complications, pneumonia, acute renal failure, acute cholecystitis, central nervous system prob- lems, hematoma/seroma, wound dehiscence, postoperative in- fection, or postoperative anemia.

Statistical Methods

Multivariable logistic regression models were applied to com- pare the likelihood of a complication or readmission following TJA for varying time periods between bariatric surgery and TJA. THA and TKA patients were assessed separately. Time between bariatric surgery and TJA was calculated in months, and grouped into categories of 06 months, 712 months, 13

18 months, 1924 months, and 25 months or more. The models

were adjusted for age at time of bariatric surgery (< 50, 5059,

60 69, and 70+ years), sex, race (white, black, other/un-

known), ethnicity (non-Hispanic, Hispanic), and insurance sta- tus (Medicaid at either admission, all other insurance). Odds ratios (OR) and 95% confidence intervals (CI) are reported. All analyses were conducted in SAS v9.3 (Cary, NC).

Results

There were 330 cases of bariatric surgery followed by a THA and 1017 cases followed by a TKA. Most patients were between

50 and 59 years old (46.4% of THA cohort; 47.0% of TKA

cohort). Patients undergoing THAwere between 22 and 77 years old (median 56 years); patients undergoing TKA were between

26 and 86 years old (median 57 years). A majority of patients

were female (69.4% THA; 76.4% TKA), white (84.5% THA; 82.2% TKA), and non-Hispanic (90.0% THA; 86.6 TKA).

Fewer than 10% of patients in both cohorts had Medicaid at either surgical encounter. The largest proportion of TKAs oc- curred more than 2 years following bariatric surgery (37.2%), followed by 712 months (19.7%), 1318 months (19.4%), 19

24 months (14.2), and zero to 6 months (9.6). Time between

bariatric surgery and THA was evenly distributed across all 6- month intervals following bariatric surgery (Table 1).

90-Day Complications

Pneumonia, acute renal failure, acute cholecystitis, and central nervous system problems were removed from the composite outcome because they did not occur in our cohort of patients. There was no association found between time of bariatric sur- gery and THA or TKA and 90-day complications in the mul- tivariable logistic regression analyses. Female patients were more likely to have a complication than male patients in the THA (OR 1.82, 95% CI 1.10, 3.00) and TKA (OR 1.56, 95%

CI 1.12, 2.17) cohorts. Age, race, ethnicity, and insurance

were not significantly associated with likelihood of a compli-

cation at 90 days for either surgery.

90-Day Readmission

Patients undergoing THA more than 6 months after bariatric surgery were significantly less likely to have a 90-day read- mission for any cause compared to patients undergoing THA within 6 months after bariatric surgery. No associations were found between age, sex, race, ethnicity or insurance status, and readmission after THA. Among TKA patients, there was

no association found between time between surgeries and re-

admission. Age, sex, race and insurance were also not associ-

ated with readmission following TKA. However, non- Hispanic patients were twice as likely to have a readmission as Hispanic patients (OR 2.02, 95% CI 1.07, 3.81; Table 2).

Discussion

Bariatric surgery continues to be a popular treatment option

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 weight reduction, bariatric surgery also helps improve chronic medical problems such as diabetes and sleep apnea, which helps lower the risk of perioperative complications associated with TJA surgery [17, 18]. Complications lead to increased costs and hospital resource utilization; Meller et al. reported a

significant increase in total health care resource consumption

for the morbidly and super obese compared to the non-obese

population undergoing TJA [18]. Given the increasing prevalence of obesity in TJA patients and the push to deliver quality care while controlling costs, bariatric surgery is offered to many morbidly obese patients with end-stage arthropathy as a legitimate means for weight loss, overall health improvement, and improving their

periroperative risk profile. With the increasing fiscal and so- cietal pressures on the American health care system, delaying elective TJA surgery with the goal of risk mitigation for these high-risk patients seems both logical and ethical [19]. Theoretically, increasing the time from bariatric surgery to elective TJA surgery would increase the benefit of the bariat-

ric procedure by allowing more time for weight loss and im-

provement of associated medical comorbidities. This study

demonstrated a significantly reduced risk of 90-day

readmissions among patients undergoing THA greater than 6 months after bariatric surgery. However, we did not find

an association of time between surgeries and the risk of 90-

day complications for THA patients, or between time from bariatric surgery to TKA and either 90-day complications or 90-day readmissions. A possible reason for the effect on

from bariatric surgery to TKA and either 90-day complications or 90-day readmissions. A possible reason for

1398

OBES SURG (2018) 28:13951401

Table 2 Adjusted odds ratios and 95% confidence intervals for complications and readmissions at 90-days for patients undergoing bariatric surgery followed by TJA

 

THA

TKA

Characteristics

90-day

90-day

90-day

90-day

complications*

readmission

complications*

readmission

Months between bariatric surgery and TJA

 

06 months

1.00 (reference)

1.00 (reference)

1.00 (reference)

1.00 (reference)

712 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)

1318 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)

1924 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)

5059 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)

6069 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 TKA patients, may be that there is more subcutaneous fat surrounding the hip. The thickness of peri-incisional subcuta- neous fat has been correlated with complications after cervical spine and cardiac surgery [2022], so it can be inferred that weight loss after bariatric surgery would be most likely to affect areas of the body with more subcutaneous fat. Although our data suggest that waiting more than 6 months after bariatric surgery before undergoing TJA, further studies are needed to be able to make a definitive recommendation on the optimal timing for TJA following bariatric surgery. There are several potential explanations for our results. First, the time course of patient response to bariatric surgery is unpredictable, and subjective factors that contribute to an individuals response are not captured in an administrative database. Golomb et al. found that the percentage of excess weight loss (%EWL) and rates of partial and complete remis- sion of type 2 diabetes mellitus were significantly lower with increased time from laparoscopic sleeve gastrectomy (LSG) [10]. Additionally, the type of bariatric surgery, restrictive, or malabsorptive, also affects the observed postoperative weight

also affects the observed postoperative weight loss and metabolic changes. Previous studies have shown that

loss and metabolic changes. Previous studies have shown that the metabolic benefits of laparoscopic Roux-en-Y gastric by- pass (LRYGB) a malabsorptive procedure are apparent before substantial weight loss occurs, while weight loss occurs before metabolic changes after restrictive procedures such as LSG [23, 24]. Comparing restrictive and malabsorptive pro- cedures, Shoar et al. found that LRYGB produced greater long-term weight loss than LSG, though no difference was observed in the rate of reduction of comorbidities [25]. TJA candidates who are referred to bariatric surgeons for consulta- tion should be made aware of the differences in time to desired postop outcome (weight loss, comorbidity improvement) that are associated with the chosen procedure, the severity of their chronic medical problems [10], and their age [10, 26]. The amount of excess weight prior to surgery has not been shown to be correlated with changes in obesity-related comorbidity status, further illustrating the multifactorial nature of each pa- tients response to bariatric surgery. There are several limitations to this study, mostly related to the database characteristics. First, we were not able to include a subgroup analysis based on the type of bariatric procedure

OBES SURG (2018) 28:13951401

1399

performed, restrictive or malabsorptive, because the informa- tion was not available in our database. Secondly, patient BMI was not consistently reported in the database, and we were unable to include this information in our analysis. Thirdly, we did not have any information available regarding the nu- tritional status of our patients, which may have provided more information on observed complication rates. Additionally, our analysis was not limited to patients who underwent bariatric surgery specifically for medical optimization after being indi- cated for TJA, which may make for a more diverse cohort because we included any and all bariatric surgery prior to TJA. Our analysis was also limited by the fact that our data- base consists of patients within a single state, and includes only patients who had both procedures, bariatric surgery and TJA, within the defined time period of the study. Despite these limitations in sample size, our study reports on one of the largest cohorts of TJA patients who have also undergone bar- iatric surgery. Finally, our stratification of patients by time from bariatric procedure to TJA was somewhat arbitrary, as there have been no studies published previously that explicitly define the expected time course for weight and metabolic changes after bariatric surgery. The strengths of this population-based database are that it includes all payer data for the entire diverse state of California, thereby giving us an opportunity to evaluate trends on a substantially sized cohort.

Appendix

Conclusion

Our retrospective study did not show that increasing the time from bariatric surgery to arthroplasty had any effect on perioperative complications for both TKA and THA. Our analyses did show a reduced rate of 90-day readmis- sion for THA, but not for TKA. Based on our results, we are unable to make a recommendation on the optimal time for TJA surgery after bariatric surgery. The value of bar- iatric surgery as part of preoperative medical optimization may lie in the nature of the metabolic changes, rather than the magnitude of weight lost. Further studies are needed to better characterize the temporal relationship of bariatric and arthroplasty surgeries.

Compliance with Ethical Standards:

Conflict of Interest Dr. Schwarzkopf reports grants and personal fees from Smith & Nephew, personal fees from Intellijoint. Ms. Lavery reports no relevant conflicts of interest. Dr. Hooper reports no relevant conflicts of interest. Dr. Parikh reports no relevant conflicts of interest. Dr. Gold reports no relevant conflicts of interest.

Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institu- tional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Table 3 ICD-9-CM diagnosis and procedure codes used to identify bariatric surgery, total hip arthroplasty (THA), total knee arthroplasty (TKA), and select complications following THA/TKA

Condition

ICD-9 code

Total joint arthroplasty (procedure codes)

Total hip arthroplasty

81.51

Total knee arthroplasty

81.54

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 [bypass: gastroduodenostomy, gastroenterostomy, gastrogastrostomy, and gastrojujenostomy without gastrectomy NOS] Laparoscopic gastroplasty [banding: silastic vertical banding and vertical banded gastroplasty (VBG)] Laparoscopic gastric restrictive procedure

44.39

44.68

44.95

BMI (diagnosis codes)

Overweight and obese

V854, 278.x

restrictive procedure 44.39 44.68 44.95 BMI (diagnosis codes) Overweight and obese V854, 278.x

1400

OBES SURG (2018) 28:13951401

Table 3 (continued)

Condition

ICD-9 code

Postoperative complication

Pulmonary embolism [1]

Deep vein thrombosis [1]

Acute myocardial infarction [1]

Respiratory failure [1]

Cerebrovascular accident [1]

415.1, 415.11, 415.19

453.4, 453.40, 453.41, 453.42

4 10 .0 0410.02, 410.10410.12, 410.20410.22, 410.30410.32, 410.40410.42, 410.50410.52, 410.60410.62, 410.70410.72, 410.80410.82,

410.90410.92

518.0, 518.51, 518.52, 518.81, 518.82

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 .0480.9, 481, 482.0482.9

Acute renal failure [1]

5 84 .5584.9, 580.0580.9, 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 thats 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. 402406

References

1. Nguyen DM, El-Serag HB. The epidemiology of obesity. Gastroenterol Clin N Am. 2010;39(1):1 7. https://doi.org/10.

2. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 19992008. JAMA. 2010;303(3):23541. https://doi.org/10.1001/jama.2009.2014.

3. Guh DP, Zhang W, Bansback N, et al. The incidence of co- morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health. 2009;9(1):88. https://doi.

4. Blagojevic M, Jinks C, Jeffery A, et al. Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis. Osteoarthr Cartil. 2010;18(1):2433. https://doi.org/

5. Springer BD, Carter JT, McLawhorn AS, et al. Obesity and the role of bariatric surgery in the surgical management of osteoarthritis of

surgery in the surgical management of osteoarthritis of the hip and knee: a review of the

the hip and knee: a review of the literature. Surg Obes Relat Dis. 2017;13(1):1118. https://doi.org/10.1016/j.soard.2016.09.011.

6. Davis AM, Wood AM, Keenan AC, et al. Does body mass index affect clinical outcome post-operatively and at five years after pri- mary unilateral total hip replacement performed for osteoarthritis? A multivariate analysis of prospective data. J Bone Joint Surg Br. 2011;93(9):1178 82. https://doi.org/10.1302/0301-620X.93B9.

7. Schwarzkopf R, Thompson SL, Adwar SJ, et al. Postoperative complication rates in the B super-obese^ hip and knee arthroplasty population. J Arthroplast. 2012;27(3):397401. https://doi.org/10.

8. Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee. Obesity and total joint arthroplasty: a literature based review. J Arthroplast. 2013;28:71421.

9. Rajgopal R, Martin R, Howard JL, et al. Outcomes and complica-

tions of total hip replacement in super-obese patients. Bone Joint J. 2013;95-B(6):75863. https://doi.org/10.1302/0301-620X.95B6.

OBES SURG (2018) 28:13951401

1401

10. Golomb I, Ben David M, Glass A, et al. Long-term metabolic effects of laparoscopic sleeve gastrectomy. JAMA Surg [Internet]. 2015 5 [cited 2015 Oct 30]; Available from: http:// archsurg.jamanetwork.com/a rticle.aspx?doi=10.1001/ jamasurg.2015.2202 .

11. Parvizi J, Trousdale RT, Sarr MG. Total joint arthroplasty in patients surgically treated for morbid obesity. J Arthroplast. 2000;15(8):

12. Kulkarni A, Jameson SS, James P, et al. Does bariatric surgery prior to lower limb joint replace ment reduce complications? Surgeon. 2011;9(1):18 21. https://doi.org/10.1016/j.surge.

13. Inacio MC, Paxton EW, Fisher D, et al. Bariatric surgery prior to total joint arthroplasty may not provide dramatic improvements in post-arthroplasty surgical outcomes. J Arthroplast. 2014;29(7):

14. Severson EP, Singh JA, Browne JA, et al. Total knee arthroplasty in morbidly obese patients treated with bariatric surgery: a compara- tive study. J Arthroplast. 2012;27(9):1696700. https://doi.org/10.

15. Werner BC, Kurkis GM, Gwathmey FW, et al. Bariatric surgery prior to total knee arthroplasty is associated with fewer postopera- tive complications. J Arthroplast. 2015;30(9):815. https://doi.org/

16. Sturm R. Increases in morbid obesity in the USA: 2000-2005. Public Health. 2007;121(7):4926.

17. Bourne R, Mukhi S, Zhu N, et al. Role of obesity on the risk for total hip or knee arthroplasty. Clin Orthop Relat Res. 2007;465:

1858.

18. Meller MM, Toossi N, Johanson NA, et al. Risk and cost of 90-day

complications in morbidly and Superobese patients after total knee arthroplasty. J Arthroplast. 2016;31(10):20918.

19. Bronson WH, Fewer M, Godlewski K, et al. The ethics of patient risk modification prior to elective joint replacement surgery. J. Bone Joint Surg. Am. 2014;96(13):e113-15.

20. Mehta AI, Babu R, Karikari IO, et al. 2012 young investigator award winner: the distribution of body mass as a significant risk factor for lumbar spinal fusion postoperative infections. Spine.

2012;37(19):16526.

21. Kozlow JH, Lisiecki J, Terjimanian MN, et al. Cross-sectional area

of the abdomen predicts complication incidence in patients under-

going sternal reconstruction. J Surg Res. 2014;192(2):6707.

22. Parvizi J, Harwin SF. Periprosthetic joint infection. J. Knee Surg. 2014;27(4):249 50.

23. Ozer K, Abdelnour S, Alva AS. The importance of caloric restric- tion in the early improvements in insulin sensitivity after Roux-en-

Y gastric bypass surgery: comment on Isbell et al. Diabetes Care.

2010;33(12):e176.

24. Thaler JP, Cummings DE. Hormonal and metabolic mechanisms of diabetes remission after gastrointestinal surgery. Endocrinology.

2009;150(6):251825.

25. Shoar S, Saber AA. Long-term and midterm outcomes of laparo- scopic sleeve gastrectomy versus Roux-en-Y gastric bypass: a sys- tematic review and meta-analysis of comparative studies. Surg Obes Relat Dis. 2017;13(2):17080.

26. Gill RS, Birch DW, Shi X, et al. Sleeve gastrectomy and type 2 diabetes mellitus: a systematic review. Surg Obes Relat Dis.

2010;6(6):70713.

X, et al. Sleeve gastrectomy and type 2 diabetes mellitus: a systematic review. Surg Obes Relat