Joint Pain and Weight Loss Surgery

A patient recently told me that his orthopedic surgeon recommended he have his weight loss surgery before having his total knee replacement. Why is that?

Total knee arthroplasty is a common and effective arthritis treatment. Although it is generally safe and effective, there can be complications. Medical complications can include thromboembolic events, heart attack, stroke, and side effects of anesthesia. Orthopedic complications include fractures around the knee implants, infection, component loosening, malalignment, instability, and continued postoperative pain. Research has shown that patients with obesity have significantly higher rates of both medical and orthopedic complications after surgery. ¹ Additionally, obesity leads to greater wear on the implant over time and therefore earlier need for revision surgery. Essentially, this means that when it comes to knee replacement, obese patients undergo greater risk for less benefit.

On the positive side, patients who are obese and are successful at weight loss frequently find that their arthritis symptoms significantly improve, potentially allowing them to delay or even eliminate the need for joint replacement. Even if they still choose to pursue joint replacement, they are now at a healthier weight and face lower complication risks and potentially have more successful outcomes. For these reasons, many orthopedic surgeons recommend that obese patients at least consider weight loss surgery prior to making the decision to have a joint replacement.

What analgesic options are available to treat musculoskeletal pain in the postoperative weight loss surgery patient who cannot tolerate oral NSAIDs?

NSAIDS are an excellent treatment for arthritis and other sources of musculoskeletal pain. Unfortunately, they have gastrointestinal side effects that make them unsafe for patients who have had weight loss surgery. However, there are other good options for pain relief. Oral medications such as acetaminophen and tramadol can also be effective. If the site of pain is relatively superficial, topical patches or gel containing either an NSAID or a local anesthetic can be applied to the area for pain relief. A recent Cochrane review found topical diclofenac sodium to be as effective as an oral NSAID with lower risk of gastrointestinal side effects. ² For arthritis in the lower extremities, a cane or walker can help decrease the weight borne by that extremity and thereby decrease pain. Additionally, arthritic joints can be injected with cortisone or other medications that can provide extended pain relief. Ultimately, a patient who has failed these treatments can consult an orthopedic surgeon to see whether there may be surgical options that would definitively treat the arthritis, such as joint replacement, spine fusion, or other procedures.

Michael Sirota, MD

Department of Orthopedic Surgery

Union Memorial Hospital

3333 N. Calvert Street

Suite 400

Baltimore, MD 21218

E-mail: michael.sirota@gmail.com

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