Losing Weight before Joint Replacement Surgery

It can be a Catch-22. A patient discusses joint replacement with her orthopedic surgeon, explaining that she needs a knee replacement in order to exercise. Her weight has ballooned, in large part, she says, because her knee pain prevents her from moving much. Before scheduling her procedure, however, the surgeon explains that her body mass index (BMI) is too high and her weight carries too great a risk to operate. The patient worries that she’ll never be able to lose weight unless she can start exercising but her knee prevents her from doing so. As a result, she feels discouraged — and hopeless.

Recently, two Eisenhower Health surgeons specializing in two very different kinds of surgery have begun collaborating on difficult cases involving obese patients needing joint replacement — John DeSantis, DO, Board Certified in Orthopedic Surgery, and Bobby Bhasker-Rao, MD, specializing in Bariatric Surgery.

“I carefully consider each situation when it involves operating on heavy people — in some cases, I am able to go ahead with the surgery — but there comes a point where the risk is too great, whether it’s a knee or a hip replacement,” says Dr. DeSantis. “Recovery is harder because of the patient’s extra weight, and it’s also a safety issue. I make weight loss recommendations to patients, but if they’re unable to succeed, I send them to see Dr. Bobby. I’ve seen some very good success in patients taking that route, losing anywhere from 80 to 120 pounds before they return to me for joint replacement surgery.”

“A lot of people who come to see me are unable to walk due to joint problems, and many of them have gained weight because they can’t walk, but they’re too heavy to have orthopedic surgery,” says Dr. Bobby. “It made sense to me to help these patients lose weight, 80 to 100 pounds, making them better candidates for successful orthopedic surgery.”

Psychological component to weight loss

The psychological component of losing weight is critical to one’s success in losing, and maintaining, weight loss.

“We recognize the psychological aspect of losing weight,” explains Dr. DeSantis. “It’s very, very difficult. Patients need the tools to lose weight and keep it off and that is what Dr. Bobby provides. Patients learn how to change their behavior.”

“We have a dietitian who counsels patients every time they walk into our office,” says Dr. Bobby. “They learn how to eat right which is a major component of our weight loss program in tandem with bariatric surgery. There is also a support group and we have psychologists if someone needs that. The changes that patients experience are so powerful and affect every aspect of their lives.”

“Obesity puts people in an immunocompromised state and they are more prone to develop cancer. Obesity also contributes to a multitude of diseases, including fatty liver disease, hypertension, high cholesterol, diabetes and coronary artery disease. As part of our routine workup for surgery, we do preventive measures and may recommend that someone has a mammogram or a colonoscopy. We have found cancers that the patient didn’t know they had.”

For some patients, their weight is life-threatening.

“One of my patients was around 320 pounds when I did a hip replacement and then a knee replacement for him,” continues Dr. DeSantis. “I followed up with another knee replacement but instead of losing weight, he gained another 100 pounds and damaged his knee. I told him he had to lose at least 100 pounds before I could replace his knee. That’s when I got Dr. Bobby involved.”

At that point, the patient was bed-ridden and in the hospital.

“When I first met this patient, I didn’t think he was going to make it,” says Dr. Bobby. “He was morbidly obese and basically, I was doing an emergency consultation. I wasn’t sure the insurance company would approve bariatric surgery, but when I explained the gravity of the situation, the surgery was approved. “

Dr. Bobby performed a sleeve gastrectomy on the patient, a procedure in which metabolic changes occur, resulting in greater weight loss in combination with a change in diet.

“In six weeks, the patient lost close to 100 pounds and I was able to revise his damaged knee,” says Dr. DeSantis. “He lost more weight following his knee revision and when I saw him one year after his dual bariatric and orthopedic procedures, he was able to walk in and out of the office on his own. I think Dr. Bobby’s surgery saved this patient’s life. He was at risk of amputation if he hadn’t lost the weight. He’s doing very well now.”

Surgery is just a tool

“I saw this patient recently and I didn’t even recognize him,” explains Dr. Bobby. “He was a completely different person when he walked in — so much happier with his life.”

“Some patients arrive in wheel chairs, barely able to walk five feet. Once they’ve lost weight and are able to have orthopedic surgery to fix a knee or hip, they can move again, return to work and feel like they’re living full lives.”

“Surgery is just a tool,” continues Dr. Bobby. “Someone could have bariatric surgery and not lose weight if they don’t change their behavior, which is why we have education classes and support groups. Weight loss surgery is not the easy way out. It’s a big commitment and requires dedication, motivation and hard work.”