Predictors of the effect of bariatric surgery on knee osteoarthritis pain

https://doi.org/10.1016/j.semarthrit.2018.02.001Get rights and content

Abstract

Introduction

Bariatric surgery reduces obesity and knee osteoarthritis (OA) pain, but some patients improve more than others. We aimed to identify characteristics that predict this knee pain improvement.

Methods

We reviewed NYU Langone Health bariatrics records (2002–2015) and called eligible patients reporting pre-operative knee pain. Patients were asked to rate their pain on a 10-point scale at three time points: before surgery, one year post-surgery, and time of survey administration. Subjects were asked about pre-operative knee injuries and surgeries, presence of OA in other joints, and OA family history. Data were analyzed using paired t-tests and ANOVA.

Results

Of 125 eligible patients reporting knee pain, we analyzed the 120 patients who had laparoscopic gastric band (LAGB) surgery. The cohort was 78.3% female, with an average age at surgery of 49.7 ± 10.2 years. There was no correlation between pre-operative body mass index (BMI) and knee pain reduction at one year post-LAGB, but the subgroup with the most BMI improvement reported the most knee improvement (p = 0.043). We found significantly better pain reduction after one year in younger patients (p = 0.009). Those with prior knee injuries improved less than those who were injury-free (p = 0.044), but a history of prior knee surgery was not similarly significant. Patients with multifocal OA improved less (p = 0.001).

Conclusion

Younger knee OA patients and those without prior knee injury or other OA involvement, experience more knee pain relief from LAGB weight loss surgery. LAGB may be a viable treatment option for knee OA pain, irrespective of the degree of obesity.

Introduction

Symptomatic knee osteoarthritis (OA) affects more than 12% of adults over the age of 60 in the United States [1], and has become increasingly prevalent at earlier ages, making it the leading cause of musculoskeletal disability. Yet current topical, oral and intra-articular options to relieve knee OA pain are often limited by inefficacy and potential toxicities [2], [3]. This has increased the need for innovation in identifying preventative and disease-modifying measures against OA [4].

Perhaps the most modifiable risk factor for the development and progression of painful knee OA is obesity [5], [6], [7], [8], defined as a body mass index (BMI) greater than 30 kg/m2. Obesity doubles the lifetime risk of knee OA [9] and increases the risk 7-fold compared to a BMI < 25 kg/m2 [10]. In 2011, the Ottawa Panel recommended a combination of physical activity and diet to achieve optimal improvement in both knee OA pain and weight loss [11]. Meanwhile, guidelines from the American College of Rheumatology (ACR) [12], the European League Against Rheumatism [13], and the Osteoarthritis Research Society International [14] have all suggested weight loss to decrease OA symptoms. Furthermore, recent data suggests that weight loss may lessen cartilage degeneration over 48 months [8]. However, obese patients with knee OA who attempt to lose weight through dietary and/or exercise programs often have difficulty participating in physical activity and only see short-term improvement [15].

More recently, investigators have evaluated the various effects of bariatric surgeries on knee OA pain, with an emphasis on the more aggressive (gastric bypass and sleeve gastrectomy) surgeries [16], [17], [18], [19]. The benefits of bariatric surgery appear to extend beyond the reduction of mechanical load on the knees, as symptomatic knee OA improvement additionally corresponds to post-bariatric reductions in inflammatory cytokines and adipokines [6], [7], [20], [21]. While the National Institute of Health guidelines support the aggressive, anatomy-altering sleeve and bypass surgeries for obese patients with a BMI ≥ 35 kg/m2 and at least one comorbidity (including knee OA), they also endorse the less invasive laparoscopic adjustable gastric banding (LAGB) for patients with a lower BMI ≥ 30 kg/m2 and at least one comorbidity [22]. Yet most insurance companies deny coverage for the LAGB for patients in the 30–35 kg/m2 range, despite early evidence that moderately obese patients achieve a significant reduction of knee OA pain following the less aggressive LAGB procedure [23], [24], [25], [26].

This study aimed to identify perioperative patient characteristics that predict improvement in symptomatic knee OA following bariatric surgery. While we expected that those achieving greater weight loss would realize the most knee pain improvement after bariatric surgery, we evaluated specific pre-bariatric characteristics as predictors of more robust knee OA relief. Ultimately, we wanted to identify groups of obese patients who should more strongly consider bariatric surgical weight loss as an alternative treatment for refractory knee OA pain and avoid total knee replacement (TKR).

Section snippets

Methods

We reviewed charts from NYU Langone Health Weight Management Program Research Registry to identify patients who underwent gastric bypass, sleeve gastrectomy, and LAGB between 2002 and 2015. We included patients ≥25 years of age (with no upper limit) at the time of surgery who reported knee pain pre-operatively and had no previous history of inflammatory or autoimmune diseases (rheumatoid arthritis, psoriatic arthritis, and lupus). We further excluded those who were deceased, declined to

Results

Of the 617 bariatric patients with documented knee pain who were eligible for the study based on the initial chart review, 159 patients met our inclusion criteria and agreed to participate in the study (Fig. 1). We excluded 25 patients who did not have a one-year post-surgery weight recorded in the database and 9 patients who reported an initial knee pain rating below 3 on the 10-point scale or could not give a rating one year post-surgery. This resulted in a final study population of 125

Discussion

We provide the first directed evaluation of perioperative patient characteristics that might influence knee pain reduction following LAGB. Patients undergoing LAGB surgery generally reported less knee pain by one year post-surgery that persisted through a mean of 10 years. Pre-operative BMI was not associated with the amount of knee OA pain reduction, though the amount of weight loss at one year (represented as change in BMI) did correlate with the amount of symptomatic knee relief. Younger

Conclusion

In conclusion, LAGB weight loss surgery results in a significant reduction of knee OA pain, especially in younger patients and those without prior knee injury or other involved joints. Overall, the amount of weight loss following LAGB can be indicative of the degree of the expected reduction in knee OA pain. Our data suggest that patient characteristics such as age, prior knee injury, and OA presence in other joints should also be considered when evaluating LAGB in the treatment algorithm for

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    Funding sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

    Conflict of interest statement: Chen: none. Bomfim: none. Youn: none. Ren-Fielding: Consultant for Arrow, Inc. Samuels: none.

    Author contributions: J.S., C.R. conceived and drafted the protocol for this study; S.X.C., F.A.B., H.A.Y. collected data; S.X.C., J.S. analyzed data; S.X.C. wrote the manuscript; S.X.C., F.A.B., H.A.Y., C.R., J.S. revised and approved the final manuscript.

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