The Influence of Obesity on Unicompartmental Knee Arthroplasty Outcomes: A Systematic Review And Meta-Analysis

Document Type : SYSTEMATIC REVIEW

Authors

1 Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore 11 Jalan Tan Tock Seng, Singapore 308433

2 Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, United Kingdom

Abstract

Obesity is associated with a greater prevalence of symptomatic knee osteoarthritis. Obese patients are thought to have worse outcomes following unicompartmental knee arthroplasty (UKA).The aim is to compare clinical and functional outcomes of UKA in obese to non-obese patients. A systematic review on six databases (PubMed, MEDLINE, Embase, Web of Science, Scopus, and CENTRAL) from inception through July 2020 was performed. We extracted data to determine revision risk (all-cause, septic, and aseptic), complication risk, and infection risk, functional outcome scores (Knee Society Score [KSS], Oxford Knee Score [OKS], and range of movement [ROM]) in patients with obesity (BMI >30kg/m2) to non-obese patients (BMI <30kg/m2). Meta-analysis was performed using a random effects model. The MINORS criteria was used for quality assessment. Twelve of 715 studies were eligible. Compared with non-obese patients, obese patients had a higher risk ratio for all-cause revision (RR 1.49; 95% CI 1.04 to 2.13; p = 0.03); aseptic revision (RR 1.36; 95% CI 1.01 to 1.81; p=0.04) and complications (RR 2.12; 95% CI 1.17 to 3.85; p=0.01). No significant differences were found in risk of septic revision and overall infection. Obese patients also had lower KSS scores (MD -3.21; 95% CI -5.52 to -0.89; p<0.01), OKS scores (MD -2.21; 95% CI -3.94 to -0.48; p=0.01), and ROM (MD -7.17; 95% CI -12.31 to -2.03; p<0.01). The average MINORS score was 14.2, indicating a moderate quality of evidence. In conclusion, the risk of revision, aseptic revision, and complications are higher in obese patients. The clinical significance of a lower functional score in obese may not be appreciable. Despite the greater risks, there is no conclusive evidence that obesity should be a contraindication to UKA. Further studies are required to corroborate the current conclusions with higher-quality study designs. Level of evidence: III

Keywords

References

  1. World Health Organization. Obesity and overweight [Internet]. Available from: https://www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight
    2. Singer SP, Dammerer D, Krismer M, Liebensteiner MC. Maximum lifetime body mass index is the appropriate predictor of knee and hip osteoarthritis. Arch Orthop Trauma Surg. 2018 Jan;138(1):99–103.
    3. Clement ND, Deehan DJ. Overweight and Obese Patients Require Total Hip and Total Knee Arthroplasty at a Younger Age. J Orthop Res Off Publ Orthop Res Soc. 2020;38(2):348–55.
    4. Harms S, Larson R, Sahmoun AE, Beal JR. Obesity increases the likelihood of total joint replacement surgery among younger adults. Int Orthop. 2007 Feb;31(1):23–6.
    5. Callahan CM, Drake BG, Heck DA, Dittus RS. Patient outcomes following tricompartmental total knee replacement. A meta-analysis. JAMA. 1994 May 4;271(17):1349–57.
    6. Diduch DR, Insall JN, Scott WN, Scuderi GR, Font-Rodriguez D. Total knee replacement in young, active patients. Long-term follow-up and functional outcome. J Bone Joint Surg Am. 1997 Apr;79(4):575–82.
    7. Norman-Taylor FH, Palmer CR, Villar RN. Quality-of-life improvement compared after hip and knee replacement. J Bone Joint Surg Br. 1996 Jan;78(1):74–7.
    8. Milligan DJ, O’Brien S, Doran E, Gallagher NE, Beverland DE.
    Twenty-year survivorship of a cemented mobile bearing Total Knee Arthroplasty. The Knee. 2019 Aug;26(4):933–40.
    9. Akizuki S, Mueller JKP, Horiuchi H, Matsunaga D, Shibakawa A, Komistek RD. In Vivo Determination of Kinematics for Subjects Having a Zimmer Unicompartmental High Flex Knee System. J Arthroplasty. 2009 Sep;24(6):963–71.
    10. Heyse TJ, El-Zayat BF, De Corte R, Chevalier Y, Scheys L, Innocenti B, et al. UKA closely preserves natural knee kinematics in vitro. Knee Surg Sports Traumatol Arthrosc. 2014 Aug;22(8):1902–10.
    11. Robertsson O, Borgquist L, Knutson K, Lewold S, Lidgren L. Use of unicompartmental instead of tricompartmental prostheses for unicompartmental arthrosis in the knee is a cost-effective alternative. 15,437 primary tricompartmental prostheses were compared with 10,624 primary medial or lateral unicompartmental prostheses. Acta Orthop Scand. 1999 Apr;70(2):170–5.
    12. Lyons MC, MacDonald SJ, Somerville LE, Naudie DD, McCalden RW. Unicompartmental versus total knee arthroplasty database analysis: is there a winner? Clin Orthop. 2012 Jan;470(1):84–90.
    13. Zhang Q, Guo W, Zhang Q, Sun R, Liu Z, Cheng L, et al. Comparison of unicompartmental knee arthroplasty and total knee arthroplasty in the treatment of unicompartmental osteoarthritis: a meta-analysis: Curr Orthop Pract. 2010 Sep;21(5):497–503.
    14. Murray DW, Parkinson RW. Usage of unicompartmental knee arthroplasty. Bone Jt J. 2018 Apr 1;100-B(4):432–5.
    15. Blaney J, Harty H, Doran E, O’Brien S, Hill J, Dobie I, et al. Five-year clinical and radiological outcomes in 257 consecutive cementless Oxford medial unicompartmental knee arthroplasties. Bone Jt J. 2017 May;99-B(5):623–31.
    16. Kozinn SC, Scott R. Unicondylar knee arthroplasty. J Bone Joint Surg Am. 1989 Jan;71(1):145–50.
    17. Riddle DL, Jiranek WA, McGlynn FJ. Yearly Incidence of Unicompartmental Knee Arthroplasty in the United States. J Arthroplasty. 2008 Apr;23(3):408–12.
    18. Pandit H, Jenkins C, Gill HS, Smith G, Price AJ, Dodd CAF, et al. Unnecessary contraindications for mobile-bearing unicompartmental knee replacement. J Bone Joint Surg Br. 2011 May;93-B(5):622–8.
    19. Lum ZC, Crawford DA, Lombardi AV, Hurst JM, Morris MJ, Adams JB, et al. Early comparative outcomes of unicompartmental and total knee arthroplasty in severely obese patients. The Knee. 2018 Jan;25(1):161–6.
    20. Xing Z, Katz J, Jiranek W. Unicompartmental Knee Arthroplasty: Factors Influencing the Outcome. J Knee Surg. 2012 May 3;25(05):369–74.
    21. Seth A, Dobransky J, Albishi W, Dervin GF. Mid-Term Evaluation of the Unicompartmental Knee Arthroplasty in Patients with BMI of 40 or Greater. J Knee Surg [Internet]. 2019 Sep 10 [cited 2020 Nov 18]; Available from: http://www.thieme-connect.de/DOI/DOI?10.1055/s-0039-1696735
    22. Nettrour JF, Ellis RT, Hansen BJ, Keeney JA. High Failure Rates for Unicompartmental Knee Arthroplasty in Morbidly Obese Patients: A Two-Year Minimum Follow-Up Study. J Arthroplasty. 2020 Apr;35(4):989–96.
    23. Bonutti PM, Goddard MS, Zywiel MG, Khanuja HS, Johnson AJ, Mont MA. Outcomes of Unicompartmental Knee Arthroplasty Stratified by Body Mass Index. J Arthroplasty. 2011 Dec;26(8):1149–53.
    24. Musbahi O, Hamilton TW, Crellin AJ, Mellon SJ, Kendrick B, Murray DW. The effect of obesity on revision rate in unicompartmental knee arthroplasty: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc [Internet]. 2020 Oct 16 [cited 2020 Nov 18]; Available from: http://link.springer.com/10.1007/s00167-020-06297-7
    25. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Reprint--preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Phys Ther. 2009 Sep;89(9):873–80.
    26. Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. Cochrane Handbook for Systematic Reviews of Interventions version 6.1 (updated September 2020) [Internet]. Available from: www.training.cochrane.org/handbook.
    27. OCEBM Levels of Evidence Working Group. The Oxford Levels of Evidence 2.
    28. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003 Sep;73(9):712–6.
    29. Walter SD, Yao X. Effect sizes can be calculated for studies reporting ranges for outcome variables in systematic reviews. J Clin Epidemiol. 2007 Aug;60(8):849–52.
    30. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol [Internet]. 2005 Dec [cited 2020 Nov 6];5(1). Available from:http://bmcmedresmethodol.biomedcentral.com/articles/10.1186/1471-2288-5-13
    31. Higgins JPT. Measuring inconsistency in meta-analyses. BMJ. 2003 Sep 6;327(7414):557–60.
    32. Zengerink I, Duivenvoorden T, Niesten D, Verburg H, Bloem R, Mathijssen N. Obesity does not influence the outcome after unicompartmental knee arthroplasty. Acta Orthop Belg. 2015 Dec;81(4):776–83.
    33. Xu S, Lim W-AJ, Chen JY, Lo NN, Chia S-L, Tay DKJ, et al. The influence of obesity on clinical outcomes of fixed-bearing unicompartmental knee arthroplasty: a ten-year follow-up study. Bone Jt J. 2019 Feb;101-B(2):213–20.
    34. Woo YL, Chen YQJ, Lai MC, Tay KJD, Chia S-L, Lo NN, et al. Does obesity influence early outcome of fixed-bearing unicompartmental knee arthroplasty? J Orthop Surg. 2017 Jan;25(1):230949901668429.
    35. Venkatesh HK, Maheswaran SS. Age and Body Mass Index Has No Adverse Effect on Clinical Outcome of Unicompartmental Knee Replacement - Midterm Followup Study. Indian J Orthop. 2019 Jun;53(3):442–5.
    36. Plate JF, Augart MA, Seyler TM, Bracey DN, Hoggard A, Akbar M, et al. Obesity has no effect on outcomes following unicompartmental knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2017 Mar;25(3):645–51.
    37. Molloy J, Kennedy J, Jenkins C, Mellon S, Dodd C, Murray D. Obesity should not be considered a contraindication to medial Oxford UKA: long-term patient-reported outcomes and implant survival in 1000 knees. Knee Surg Sports Traumatol Arthrosc. 2019 Jul;27(7):2259–65.
    38. Murray DW, Pandit H, Weston-Simons JS, Jenkins C, Gill HS, Lombardi AV, et al. Does body mass index affect the outcome of unicompartmental knee replacement? The Knee. 2013 Dec;20(6):461–5.
    39. Polat AE, Polat B, Gürpınar T, Çarkçı E, Güler O. The effect of morbid obesity (BMI ≥ 35 kg/m2) on functional outcome and complication rate following unicompartmental knee arthroplasty: a case-control study. J Orthop Surg [Internet]. 2019 Dec [cited 2020 Nov 18];14(1). Available from: https://josr-online.biomedcentral.com/articles/10.1186/s13018-019-1316-5
    40. Sundaram K, Warren J, Anis H, George J, Murray T, Higuera CA, et al. An increased body mass index was not associated with higher rates of 30-day postoperative complications after unicompartmental knee arthroplasty. The Knee. 2019 Jun;26(3):720–8.
    41. Kandil A, Werner BC, Gwathmey WF, Browne JA. Obesity, Morbid Obesity and their Related Medical Comorbidities are Associated with Increased Complications and Revision Rates after Unicompartmental Knee Arthroplasty. J Arthroplasty. 2015 Mar;30(3):456–60. 42. Lash H, Hooper G, Hooper N, Frampton C. Should a Patients BMI Status be Used to Restrict Access to Total Hip and Knee Arthroplasty? Functional Outcomes of Arthroplasty Relative to BMI - Single Centre Retrospective Review. Open Orthop J. 2013;7:594–9.
    43. Naal FD, Neuerburg C, Salzmann GM, Kriner M, von Knoch F, Preiss S, et al. Association of body mass index and clinical outcome 2 years after unicompartmental knee arthroplasty. Arch Orthop Trauma Surg. 2009 Apr;129(4):463–8.
    44. Thompson SAJ, Liabaud B, Nellans KW, Geller JA. Factors associated with poor outcomes following unicompartmental knee arthroplasty: redefining the ‘classic’ indications for surgery. J Arthroplasty. 2013 Oct;28(9):1561–4.
    45. Boyer B, Bordini B, Caputo D, Neri T, Stea S, Toni A. What are the influencing factors on hip and knee arthroplasty survival? Prospective cohort study on 63619 arthroplasties. Orthop Traumatol Surg Res. 2019 Nov;105(7):1251–6.
    46. Affatato S, Caputo D, Bordini B. Does the body mass index influence the long-term survival of unicompartmental knee prostheses? A retrospective multi-centre study. Int Orthop. 2019 Jun;43(6):1365–70.
    47. Berend KR, Lombardi AV. Liberal indications for minimally invasive oxford unicondylar arthroplasty provide rapid functional recovery and pain relief. Surg Technol Int. 2007;16:193–7.
    48. Haughom BD, Schairer WW, Hellman MD, Nwachukwu BU, Levine BR. An Analysis of Risk Factors for Short-Term Complication Rates and Increased Length of Stay Following Unicompartmental Knee Arthroplasty. HSS J Musculoskelet J Hosp Spec Surg. 2015 Jul;11(2):112–6.
    49. Brown NM, Sheth NP, Davis K, Berend ME, Lombardi AV, Berend KR, et al. Total Knee Arthroplasty Has Higher Postoperative Morbidity Than Unicompartmental Knee Arthroplasty: A Multicenter Analysis. J Arthroplasty. 2012 Sep;27(8):86–90.
    50. Epstein AM, Read JL, Hoefer M. The relation of body weight to length of stay and charges for hospital services for patients undergoing elective surgery: a study of two procedures. Am J Public Health. 1987 Aug;77(8):993–7.
    51. Obesity and Total Joint Arthroplasty. J Arthroplasty. 2013 May;28(5):714–21.
    52. White RH, Henderson MC. Risk factors for venous thromboembolism after total hip and knee replacement surgery. Curr Opin Pulm Med. 2002 Sep;8(5):365–71.
    53. van der List JP, Chawla H, Zuiderbaan HA, Pearle AD. The Role of Preoperative Patient Characteristics on Outcomes of
    Unicompartmental Knee Arthroplasty: A Meta-Analysis Critique. J Arthroplasty. 2016 Nov;31(11):2617–27.
    54. Biswas D, Van Thiel GS, Wetters NG, Pack BJ, Berger RA, Della Valle CJ. Medial unicompartmental knee arthroplasty in patients less than 55 years old: minimum of two years of follow-up. J Arthroplasty. 2014 Jan;29(1):101–5.
    55. Pennington DW, Swienckowski JJ, Lutes WB, Drake GN. Unicompartmental knee arthroplasty in patients sixty years of age or younger. J Bone Joint Surg Am. 2003 Oct;85(10):1968–73.
    56. Kort NP, van Raay JJAM, van Horn JJ. The Oxford phase III unicompartmental knee replacement in patients less than 60 years of age. Knee Surg Sports Traumatol Arthrosc. 2007 Apr;15(4):356–60.
    57. Price AJ, Dodd C a. F, Svard UGC, Murray DW. Oxford medial unicompartmental knee arthroplasty in patients younger and older than 60 years of age. J Bone Joint Surg Br. 2005 Nov;87(11):1488–92.
    58. Lo Presti M, Raspugli GF, Reale D, Iacono F, Zaffagnini S, Filardo G, et al. Early Failure in Medial Unicondylar Arthroplasty: Radiographic Analysis on the Importance of Joint Line Restoration. J Knee Surg. 2019 Sep;32(09):860–5.
    59. Johnston H, Abdelgaied A, Pandit H, Fisher J, Jennings LM. The effect of surgical alignment and soft tissue conditions on the kinematics and wear of a fixed bearing total knee replacement. J Mech Behav Biomed Mater. 2019;100:103386.
    60. El-Galaly A, Kappel A, Nielsen PT, Jensen SL. Revision Risk for Total Knee Arthroplasty Converted from Medial Unicompartmental Knee Arthroplasty: Comparison with Primary and Revision Arthroplasties, Based on Mid-Term Results from the Danish Knee Arthroplasty Registry. J Bone Jt Surg. 2019 Nov;101(22):1999–2006.
    61. Willis-Owen CA, Brust K, Alsop H, Miraldo M, Cobb JP. Unicondylar knee arthroplasty in the UK National Health Service: an analysis of candidacy, outcome and cost efficacy. The Knee. 2009 Dec;16(6):473–8.
    62. Epinette J-A, Brunschweiler B, Mertl P, Mole D, Cazenave A, French Society for Hip and Knee. Unicompartmental knee arthroplasty modes of failure: wear is not the main reason for failure: a multicentre study of 418 failed knees. Orthop Traumatol Surg Res OTSR. 2012 Oct;98(6 Suppl):S124-130.
    63. Kerkhoffs GMMJ, Servien E, Dunn W, Dahm D, Bramer JAM, Haverkamp D. The influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review. J Bone Joint Surg Am. 2012 Oct 17;94(20):1839–44.
The Archives of Bone and Joint Surgery
Volume 9, Issue 6
November 2021
Pages 618-632

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History

  • Receive Date: 06 May 2021
  • Accept Date: 28 July 2021

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