National orthopedic organizations do not have clear guidelines for obese and overweight patients seeking joint replacements, but individual physicians have different cutoffs — and the variation is complicating care, The New York Times reported Sept. 4.
While the use of BMI scores is a criticized subject, orthopedic surgeons say there are dire risks of operating on patients with high BMI scores. One risk is infections in the prosthetic joint, which can lead to amputations or death, according to the Times.
In a recent survey, less than half of orthopedic surgeons said they would operate on a patient with a BMI over 40, 11% said they would operate on a BMI higher than 50 and only 3% said the same for a BMI surpassing 55. More than 26 million American adults fell into these categories in 2017 to 2018.
The number is higher now as obesity and arthritis levels increase, but the American Academy of Orthopedic Surgeons and the American Association of Hip and Knee Surgeons do not have a set BMI cutoff for operations.
Four things to know about the dilemma, according to the Times:
1. Payers often do not cover these operations, and hospitals also might refuse to operate on these patients due to their longer stays and they are considered "money-losers."
2. Stigma against obesity plays a role, as some physicians believe patients can simply lose weight through personal decisions, patient advocates said.
3. Popular weight loss medications, such as Wegovy, might help patients shed weight but BMI levels might barely budge. For example, a woman who is 5 feet, 5 inches tall and has a BMI of 50 would have to lose 20% of her weight to achieve a BMI of 40; Wegovy's average weight loss is 15% after 68 weeks.
4. Despite the nuances and prejudices about obesity — a complex condition that requires complex care — the risks of operating on a person with a high BMI are clear.
"I have a moral obligation to do no harm," Nathanael Heckmann, MD, an assistant orthopedic surgery professor at the Keck School of Medicine of USC, told the Times. "It goes against my moral fiber to do something that is prohibitively high risk."