The challenges of Weight management and knee replacement – before and after surgery
Ross A. Hauser, MD, Caring Medical Florida, Fort Myers, FL
Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Florida, Fort Myers, FL
David N. Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, IL
Weight management, not joint replacement. Knee replacement is not an easy way to weight loss.
Research: Knee replacement does not help many people lose weight.
Many patients are under the assumption that the quickest way to attack their obesity problem is to get a knee replacement. The thinking is that is they eliminate their knee pain they will be able to exercise and lose weight. Surgeons are being told to tell patients that is not true for many obese patients.
In an August 2016 study published in the The Journal of rheumatology, (1) doctors at the University of Texas MD Anderson Cancer Center suggested that following knee replacement, increasing BMI (Body Mass Index – Obesity) and rising anxiety levels and decreasing levels of positive social interactions were associated with increased patient costs (the need for continued care) following total knee replacement. The greater the obesity the greater the patient need for care (cost) following the knee replacement. What is this need? An April 2019 study from the Feinberg School of Medicine, Northwestern University published in the Journal of Clinical Nursing (2) offering this assessment:
- “Many patients undergoing knee replacement surgery are overweight or obese. While obesity treatment guidelines encourage diet and activity modifications, gaps exist in understanding social and environmental (factors) determinants of these behaviours for knee replacement patients. Identifying these determinants is critical for treatment, as they are likely amplified due to patients’ mobility limitations, the nature of surgery and reliance on others during recovery.”
Here were the problems identified:
- The people who continued with weight issues following knee replacement, despite the reliance on others to help them and their own mobility issues, still had availability of unhealthy food choices. (this could be a problem of enablers).
- Positive results were achieved with weight loss when there was an availability of healthy food, and keeping unhealthy options “out of sight,” and social support.
- Weather was the primary activity barrier, while facilitators included access to physical activity opportunities and social support.
Practitioners treating knee replacement patients would be aided by an understanding of patients’ perceived social and environmental factors that impede or facilitate surgical progress. Particularly for those directly interacting with patients, like nurses, physiotherapists, or other professionals, support from health professionals appears to be a strong facilitator of adherence to diet and increased activity.
- This study suggests that to help obese patients lose weight after knee replacement, they need a team to help them adhere to diet.
Research: It is unclear whether total knee replacement facilitates weight reduction.
Is the surgery a “barrier” to weight loss?
An earlier study from Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University and the Department of Exercise Science, University of South Carolina published in the the journal BioMed Central musculoskeletal disorders (3) made these observations:
- Most knee replacement patients are overweight/obese, yet are commonly excluded from evidence-based weight loss programs due to mobility limitations and barriers faced around the time of surgery.
- The purpose of this study was to identify knee replacement patient preferences for weight loss programs and qualitatively understand previous motives for weight loss attempts as well as strategies used to facilitate behavior changes.
This study focused on patients who were either scheduled to have knee replacement or had one recently completed within the last 3 months (of the time of the study participation) were recruited to participate. Patients completed a brief weight loss program preference questionnaire assessing preferred components of a weight loss program (i.e. self-monitoring, educational topics, program duration).
- Twenty patients (11 pre-operative and 9 post-operative) between 47 and 79 years completed the study (55% male, 90% White, and 85% with a BMI ≥25 kg/m2).
- Patients reported a preference for a weight loss program that starts before surgery, is at least 6 months in duration, and focuses both on diet and exercise.
- The majority of patients preferred to have a telephone-based program and wanted to track diet and physical activity on a smartphone application.
- The most common motive for weight loss mentioned by patients related to physical appearance (including how clothing fit), followed by wanting to lose weight to improve knee symptoms or to prevent or delay knee replacement. Strategies that patients identified as helpful during weight loss attempts included joining a formal weight loss program, watching portion sizes, and self-monitoring their dietary intake, physical activity, or weight.
If you are reading this article, you or a loved one facing knee replacement surgery and if you are like your counterparts in this study, you want to look better than you want to your knee to work better. This would likely not be the dominating motive for someone who is self-employed or still working. As discussed above, this type of weight loss program does require a lot of costs.
Obese patients are more likely to require total knee replacement -It is unclear whether total knee replacement facilitates weight reduction
Doctors in the United Kingdom reported these findings in the journal Maturitis (4)
- There is a proven association between obesity and knee osteoarthritis, and obesity is suggested to be the main modifiable risk factor.
- Obese patients are more likely to require total knee replacement
- It is unclear whether total knee replacement facilitates weight reduction
- Surgery in obese patients is more technically challenging.
- This is reflected in the evidence, which suggests
- higher rates of short- to medium-term complications following total knee replacement, including wound infection and medical complications, resulting in longer hospital stay, and potentially higher rates of malalignment, dislocation, and early revision.
- This is reflected in the evidence, which suggests
It is better to lose weight before total knee replacement
Research: High patient weight is a risk factor for mechanical implant failure and some knee replacement manufacturers list obesity as a contraindication for implant use.
In another study from the United Kingdom, doctors were much more critical of putting implants into obese patients as they noted in the Annals of the Royal College of Surgeons of England.(5)
High patient weight is a risk factor for mechanical implant failure and some manufacturers list obesity as a contraindication for implant use. Doctors in the United Kingdom were amazed to find out that:
- A total of 10,745 patients in a two year period 2012-2013 received knee or hip implants against manufacturer recommendations.
- 16% of all obese patients) received implants against manufacturer recommendations.
Research: overweight patients are at a more than 40% greater risk and obese patients are at more than a 100% increased risk of knee replacement surgery compared to patients with normal weight
Weight reduction strategies could potentially reduce the need for knee replacement surgery by 31% among patients with knee osteoarthritis.
The simple summary to all the research listed above is this:
Doctors at Oxford University publishing in the journal Arthritis and Rheumatology (6) found that overweight patients are at a more than 40% greater risk and obese patients are at more than a 100% increased risk of knee replacement surgery compared to patients with normal weight. Weight reduction strategies could potentially reduce the need for knee replacement surgery by 31% among patients with knee osteoarthritis.
In this video David N. Woznica, MD discusses what we see in patients who come in with knee pain in the knee that they had replaced.
Many of the patients that we see with knee pain after knee replacement have pain on the outside of the knee. This is where the ligaments and the tendons are. Most often these connective tissue are damaged and under constant strain. This causes the the knee to wobble, unstable, and cause hypermobility. This pulls and tugs at the ligaments and tendons which causes the patient a lot of pain.
Some patients have nerve irritations. This nerve irritation can be below or above the knee or along the kneecap. We would treat these problems with nerve release therapy.
The vicious cycle: I can’t lose weight because I am not mobile. I am not mobile because of my knee pain. I can’t lose weight
In our more than 26 years years experience in helping people with knee pain, we have seen many patients who were overweight and considered obese. If you are reading this article, you know that there is “no magic pill,” there is “no magic formula,” to help you overcome the challenges of weight loss and knee pain. The most simple advice is that a person who desires to lose weight must burn more calories than they take in. This of course is easier said than done and the rationale behind some of the studies that we mentioned above in the tools and team required to help someone make it “easier done than said.”
We do present a lot of information on this website that may help provide an understanding in how one may lose weight with knee pain:
Here is the snippet of this article: A patient comes in on a recommendation from a friend. “I am here because I have very bad knee pain . . . here is my story: I went to the doctor for my check up. My blood work revealed slightly elevated cholesterol and I was advised that I need to take and was given prescriptions for medications that would lower my cholesterol. As a side note I told my doctor that I did have some knee pain from a new exercise program. I said with confidence that hopefully I can control my cholesterol with this new exercise program. My doctor said, “go easy on my knee.”
Soon after taking these new cholesterol medications I felt a sharp pain in my knee. I wasn’t doing anything but walking to my car in the parking lot. My wife drove us home and she got me to the chair and we elevated my leg and got plenty of ice on it . .
In this article we explore the challenges people with unmanaged or uncontrolled type 2 diabetes face with knee pain. If you are someone suffering with type 2 diabetes and knee pain, one challenge you may be facing is a diminished ability to heal your damaged knee. This non-healing will eventually lead to irreversible knee degenerative disease and the eventual recommendation to a knee replacement. Knee replacement complications in Type 2 diabetes is of course another great concern.
When people come into our clinics with significant knee pain, they will often ask our clinicians about what type of diet they should be on. Proper weight and proper diet are of course a very important element in healing. But how much can diet realistically do for your knee pain?
The right food stimulates healing, the wrong food can cause inflammatory reactions and make your knees feel worse. A realistic expectation one may have with food choice change is that you will probably look a little better, feel a little better, have a little more energy, and your knees may hurt less. To what degree depends on how aggressive you are with a change of diet and healing.
If this article has helped you understand the problems of obesity and joint pain and you would like to explore Prolotherapy as a possible remedy for your joint pain, ask for help and information from our specialists
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