Alicia Klein last walked on her own in January 2021. She suffers from constant pain from hip inflammation and uses a walker and wheelchair.
The problem is that she’s obese — her body mass index is over 50 — and for someone like Klein, 54, of Reading, Pennsylvania, finding a doctor willing to perform joint replacement surgery that could ease her pain is a nearly impossible task.
Dilemmas like hers are rocking orthopedic medicine as obesity rates soar and, with them, arthritis: What should orthopedic surgeons do when faced with a patient whose BMI is so high?
Although the science of body mass index has been frequently criticized, doctors say risk Operating on patients with a BMI at the upper end of the obesity threshold can have dire consequences, such as deep infection of the artificial joint, which can lead to amputation or death. escalate As the patient’s BMI increases.
Although professional organizations (American Orthopaedic Association and American College of Hip and Knee Surgeons) do not have clear BMI cutoffs for surgery, orthopaedic surgeons have their own cutoffs.
and othersFewer than half of orthopedic surgeons A survey published last year They announced that they would perform surgery on patients with a BMI of 40 or more. 22 million 100% of American adults fell into this category in 2017-2018. Of the 3.9 million Americans with a BMI over 50, only 11% perform surgery, and patients with a BMI over 55 are almost universally rejected. Only 3% of American orthopedic surgeons perform surgery.
In addition, even if doctors want to perform surgery, insurance companies often refuse to pay. These patients tend to stay in hospital for a long time and take a long time to treat, so hospitals may also refuse to operate on them because they are considered to be in the red.
Dr. Nathaniel Heckman of the University of Southern California said the result was “entire populations being denied orthopedic care.”
The patient suspects that stigma against obesity may be a factor.
“It’s just the cliche: ‘You can’t have this surgery because you’re too heavy,'” says Lynn Rubinette, 66, of Austin, Texas, who said she fought for more than a year to get hip replacement surgery. Her BMI is 43.
New obesity drugs like Wegobee and Zepbound may work for some, but they won’t be enough for many. For example, a woman who is 5’5″ and has a BMI of 50 weighs 300 pounds. To get to a BMI of 40, she would have to lose 60 pounds, or 20% of her body weight, and even with the new drugs, very few people can do that.
At stake are thorny ethical questions: Is it really OK to replace joints in severely obese patients? And who should make that decision?
Patients say doctors often hold the outdated belief that patients can lose weight if they make a real, serious effort.
“When people have hip replacements, they gain the weight back because they can stand up and walk to the refrigerator again,” one surgeon joked to Rubinette.
Rubinette added that the joke reveals a “deep lack of compassion and understanding of how complex and difficult it is to sustainably lose 50-100+ pounds of excess weight.”
But doctors say balancing patient needs with commitments to medical ethics can be a real challenge.
Among them is Dr. Yale Fillingham of the Rothman Orthopaedic Institute in Philadelphia, who is developing updated guidelines for the American Association of Hip and Knee Surgeons.
“This is a difficult question,” he says. “There’s a lot of nuance and different perspectives involved in determining whether a BMI cutoff is a good thing or a bad thing.”
Surgeons say they are aware that the presence or absence of other chronic diseases, such as diabetes, can affect risk, but they note that BMI is an independent risk factor, so they use it, and they say they are acutely aware of the risks of operating on very heavy patients.
“Given the survival rates of patients with infections and how serious and deadly they can be, many surgeons prefer to tell their patients, ‘Sorry, I can’t help you,’ rather than feel responsible for a dire outcome,” Dr Fillingham said.
Dr. Charles P. Hannon, an orthopedic surgeon at the Mayo Clinic in Rochester, Minnesota, says he doesn’t set strict BMI standards, but patients with a higher BMI need to understand what they could be facing. While the risk of infection may be less than 10%, “if you get it, it’s 100%,” he said.
Hannon said a patient recently came to him after another doctor had performed a hip replacement, and the wound would not heal and developed a deep infection in the joint.
“We’re trying to save his leg,” Dr. Hannon said.
For Klein, nothing is worse than the life she’s living, not even death, she said.
Her problems began in 2012, when she was 42 and suffered severe pain in her left hip, making it difficult for her to sleep. The doctor’s diagnosis was osteoarthritis. The prescription was to lose weight.
Eventually, she was no longer able to walk. She had been swimming since 2006, but one day in early 2021, the pain became so severe that she could no longer swim.
Shortly after that terrible day, Klein went to a local orthopedic surgeon in private practice.
To her surprise, the doctor made no mention of her weight, instead suggesting she replace both of her hips, starting with her left.
The surgery took place in April 2021. Her BMI was 45. She was discharged the next day, but continued to bleed from the incision for 20 weeks and her left hip was so painful she could not walk.
She went to the Rothman Institute for a second opinion and was seen by Dr. Fillingham.
The pain? It was due to a deep infection. She had to have her hip removed and have a temporary implant put in until the infection cleared up. She was hospitalized for a month and given intravenous antibiotics for 55 days.
Three months later, Dr. Fillingham implanted a new left hip in her. She was in hospital for four days, but had no complications.
However, pain in his right hip made it difficult for him to walk, and his BMI soared to 50.
Dr. Fillingham couldn’t help. His orthopedic practice will allow joint replacements in patients who have developed infections after previous surgery, but won’t allow primary joint replacements in patients with a BMI over 50. Mr. Klein is now 59.
Fran Ryan of Reno, Nevada, had almost given up on finding a doctor willing to give her a new hip joint: With a BMI of 41, surgeons told her she was simply too overweight.
“I’m in my early 50s and I couldn’t walk,” she says. “I have three kids and we walk and hike.”
But not anymore: She got a handicapped sticker put on her car after a physical therapist told her that even walking through a Costco was “too much walking,” only to find that the short walk left her in excruciating pain.
She eventually found a surgeon willing to perform the operation, Dr. Derek Amanatullah, at Stanford University, a four-hour drive from her home.
“He made me feel like a human being,” she says, “and other doctors take that away. It doesn’t matter if you’re in pain because you’re fat.”
That was last August.
“My surgery was a robotic-assisted outpatient procedure,” she said. There were no complications.
Her son got married on September 16th.
“All I wanted was to dance with him at his wedding,” said Ryan, which she did, even though she “had to use a cane.”
“My life has improved dramatically,” she added, but it’s not back to normal. “Not being able to walk has caused me to lose a lot of muscle tone,” she explained.
“But,” she says, “I had to persevere and keep looking for options even after hitting a wall.
“I know not everyone has those resources,” Ryan said.
For those with a high BMI, seeking help may be futile.
Janet Daniels, 56, of Alexandria, Virginia, has struggled with obesity since she was 8 years old. Despite diets and exercise programs, she couldn’t get her weight under control. Her BMI is 61.3. She was repeatedly told that no one would perform surgery on her.
She recently saw a new orthopedic surgeon, her fifth so far, who looked at her x-rays and exclaimed, “The bones in both knees are touching bone.”
But he too refused the operation.
She fired back: “How many plastic surgeons have you been to tell me, ‘You’re fat, you have to suffer’?”
As she left, he handed her his nutritionist business card.
Klein finally found a doctor willing to replace her right hip, but he wants her to lose 30 pounds.
“He didn’t even schedule a follow-up appointment with me,” Klein said. “He told me to call him back when I’d lost 30 pounds.”
She has been trying to lose weight since April and has been taking Wegovy for a month, but so far she hasn’t lost enough weight.
“I can’t continue living like this,” Klein said.
Dr. Heckman understands this: Though he hasn’t treated Ms. Klein, he regularly sees patients with very high BMIs, and sometimes he says yes, but with a patient like her he would say no.
If a patient who has had an infection in one hip has the other replaced, he is more likely to get another infection, and congestive heart failure makes the surgery even more risky. He fears the surgery may kill him.
“I have a moral obligation to do no harm,” Dr. Heckman said. “It would be against my moral conscience to do something that is prohibitively risky.”
