Predictors of the effect of bariatric surgery on knee osteoarthritis pain
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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An Update on the Management and Optimization of the Patient with Morbid Obesity Undergoing Hip or Knee Arthroplasty
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2023, Osteoarthritis and CartilageEnvironmental Risk Factors for Osteoarthritis: The Impact on Individuals with Knee Joint Injury
2022, Rheumatic Disease Clinics of North AmericaCitation Excerpt :However, other diets that focus on supervised caloric restriction reduce body weight and improve function.64,68 There is also consistent improvement in knee OA-related symptoms after bariatric surgery,69–71 further suggesting the important role of bodyweight in the disease course and patient experience of OA. After ACL injuries, changes in body mass and composition occur in both the immediate time frame after injury and reconstruction, as well as years later.
The influence of bariatric surgery on hip and knee joint pain: a systematic review
2021, Surgery for Obesity and Related DiseasesCitation Excerpt :One study reported a nonsignificant decrease in the number of participants with hip pain [33]. Of the 23 studies evaluating knee pain, 14 reported a statistically significant reduction in the participants’ knee pain intensity scores [35,36,39,40–42,45,46–49,51,52,54]. Results of 2 other studies also suggested (nonsignificant) reductions in knee pain intensity [38,49].
Obesity, Bariatric Surgery, and Hip/Knee Arthroplasty Outcomes
2021, Surgical Clinics of North AmericaCitation Excerpt :In addition to improved gait mechanics and decreased joint load, bariatric surgery also has been shown to alter levels of several adipocytokines within the first year after bariatric surgery. For example, the decrease in leptin following bariatric surgery has been shown to correspond directly to the reduction in osteoarthritic knee pain.54 Some studies suggest, however, that weight loss leads to increased torque across joints due to the increased stride length and gait velocity that accompany weight loss,55,56 with some suggestion that higher weight loss after bariatric surgery could increase the likelihood of undergoing TJA.57
Diabetes mellitus and osteoarthritis
2020, Diabetes Mellitus: Impact on Bone, Dental and Musculoskeletal Health
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.