Obesity Surgery (2018) 28:1395–1401

https://doi.org/10.1007/s11695-017-3034-6

ORIGINAL CONTRIBUTIONS

Bariatric Surgery and Time to Total Joint Arthroplasty: Does It Affect

Readmission and Complication Rates?
Ran Schwarzkopf 1 & Jessica A. Lavery 2 & Jessica Hooper 1 & Manish Parikh 3 & Heather T. Gold 1,4

Published online: 22 November 2017

# Springer Science+Business Media, LLC, part of Springer Nature 2017

Abstract
Background Bariatric surgery is frequently recommended prior to total joint arthroplasty (TJA) for morbidly obese patients with
end-stage arthropathy. Current published data on the efficacy of bariatric surgery for preoperative medical optimization has
yielded mixed results, and the effect of time from bariatric surgery to TJA on the preoperative risk profile is not well defined. Our
study evaluated the effect of time from bariatric surgery to TJA on 90-day complication and readmission rates.
Methods We utilized the Healthcare Cost and Utilization Project (HCUP) California State Inpatient Database (SID) to identify
patients who underwent TJA following bariatric surgery between 2007 and 2011. Primary endpoints were 90-day complication
rates and all-cause 90-day readmission rates following TJA.
Results We identified 330 cases of bariatric surgery followed by total hip arthroplasty (THA) and 1017 cases followed by total
knee arthroplasty (TKA). There were no significant demographic differences among patients who underwent TJA greater than or
less than 6 months after bariatric surgery. Patients undergoing THA more than 6 months after bariatric surgery were significantly
less likely to be readmitted within 90 days for any cause. There was no association between time from bariatric surgery to THA or
TKA and 90-day complications.
Discussion Delaying THA at least 6 months after bariatric surgery may help reduce the rate of 90-day readmissions in this high-
risk patient population. Arthroplasty surgeons recommending bariatric surgery as preoperative risk modification should consider
the patient’s overall nutritional status, medical comorbidities, and overall response to surgery prior to booking for TJA.

Keywords Total joint arthroplasty . Medical optimization . Bariatric surgery . Obesity . Readmission rate . Perioperative
complication rate

Investigation performed at NYU Langone Medical Center in New York,
New York.
This study was determined to be exempt from review by the institutional
review board.
* Jessica Hooper
jessica.hooper@nyumc.org
1 lence of medical comorbidities in the obese population, these
Department of Orthopedic Surgery, New York University Hospital
for Joint Diseases, 301 E 17th Street, Suite 1402, New
York, NY 10003, USA
2
Department of Biostatistics, New York University Langone Medical
Center, 550 First Avenue, New York, NY 10016, USA
3
Department of Surgery, New York University Langone Medical
Center, 550 First Avenue, New York, NY 10016, USA
4
Department of Population Health, New York University Langone
Medical Center, 550 First Avenue, New York, NY 10016, USA
Background
The prevalence of obesity in adults in the USA has increased
by 4.9% over the past decade [1, 2]. Obesity contributes to
many chronic medical conditions such as obstructive sleep
apnea, hypertension, hyperlipidemia, diabetes mellitus, and
cardiovascular disease [3]. In addition to the increased preva-
patients are also more likely to have metabolic derangements
and have a higher prevalence of malnourishment compared to
non-obese patients [3].
Obesity has also been identified as a risk factor for the
development of osteoarthritis; increased loads at the hip, and
especially at the knee joints, during activities of daily living
are directly related to increased weight [4, 5]. Obese patients
consequently develop end-stage arthropathy more quickly
1396 OBES SURG (2018) 28:1395–1401

than their non-obese peers, and are often younger with more first TJA was selected. Patients who underwent a TJA prior to
medical comorbidities when they are considered for total joint bariatric surgery were excluded (n = 853). To confirm that no
arthroplasty (TJA). Due to the increased technical difficulty of TJA occurred in the year prior to bariatric surgery, we allowed
the operation, malnourished status, and overall poorer health, for a 1-year lookback from bariatric surgery discharge to eval-
obesity is associated with higher complication rates and uate whether TJA occurred, with observation starting in 2006
readmissions following TJA [6, 7]. A body mass index for the 2007 bariatric surgery patients. We excluded patients
(BMI) > 40 kg/m2 has been observed as a threshold at which with more than one bariatric surgery between 2006 and 2011
complications and revision rates increase among TJA patients and patients who underwent TJA for fracture, such as femoral
[8]. The super obese (BMI > 50 kg/m2) patient population has neck fractures. Our final sample included 1347 patients.
been reported to have an even higher risk for perioperative The primary outcomes were 90-day complications and all-
complications [9]. cause 90-day readmission following the TJA. A complication
Bariatric surgery is often recommended prior to TJA for was assessed at the TJA surgical admission and at any read-
morbidly obese patients with end-stage arthropathy. Bariatric mission within 90 days, and included one or more of the
procedures have proven to be a more effective means of following based on ICD-9-CM codes (Table 1): pulmonary
weight loss than nonsurgical interventions in morbidly obese embolism, deep vein thrombosis, acute myocardial infarction,
patients [10], and can help induce partial or complete remis-
sion of obesity-related comorbidities such as type 2 diabetes Table 1 Characteristics of patients undergoing bariatric surgery
mellitus, hypertension, and dyslipidemia [10]. Previous stud- followed by total joint arthroplasty in California (n = 1347), 2007–2011
ies have examined the effect of bariatric surgery prior to TJA Characteristics Total hip arthroplasty Total knee arthroplasty
on perioperative complications and postoperative outcomes, (n = 330) (n = 1017)
but the results remain inconclusive [11–15]. n (%) n (%)
It is not clear from the published evidence how time from
90-day complications
bariatric surgery to TJA surgery affects the TJA risk profile of
an obese patient. We sought to evaluate how the time (months) No 181 (54.8) 687 (67.6)
from bariatric surgery to TJA surgery affected the rate of peri- Yes 149 (45.2) 330 (32.4)
operative TJA complications and readmissions. We hypothe- 90-day all-cause readmission
sized that increasing the time between bariatric surgery to TJA No readmissions 256 (77.6) 842 (82.8)
surgery would allow patients to lose weight and adjust to the Readmission 74 (22.4) 175 (17.2)
metabolic changes that occur after bariatric surgery, leading to Months between bariatric surgery and TJA
lower complication and readmission rates following TJA. 0–6 months 61 (18.5) 98 (9.6)
7–12 months 85 (25.8) 200 (19.7)
13–18 months 53 (16.1) 197 (19.4)
Methods 19–24 months 43 (13.0) 144 (14.2)
> 24 months 88 (26.7) 378 (37.2)
Data Source Age (years; at bariatric surgery)
< 50 years 85 (25.8) 185 (18.2)
We utilized the Healthcare Cost and Utilization Project 50–59 years 153 (46.4) 478 (47.0)
(HCUP) California State Inpatient Database (SID) to identify 60–69 years 80 (24.2) 315 (31.0)
patients that underwent total joint arthroplasty (TJA) follow- 70+ years 12 (3.6) 39 (3.8)
ing bariatric surgery between 2007 and 2011. The HCUP SID Sex
is a population-based dataset encompassing all hospital dis- Male 101 (30.6) 240 (23.6)
charge records from the state of California. ICD-9-CM diag- Female 229 (69.4) 777 (76.4)
nosis and procedure codes were used to identify bariatric sur- Race
gery, total hip arthroplasty (THA), total knee arthroplasty White 279 (84.5) 836 (82.2)
(TKA), and select complications following THA/TKA Black 28 (8.5) 89 (8.8)
(Table 3 in Appendix). These data are de-identified and are Other/unknown 23 (7.0) 92 (9.0)
exempt from IRB review. Ethnicity
Non-Hispanic 300 (90.9) 881 (86.6)
Cohort Selection Hispanic 30 (9.1) 136 (13.4)
Insurance
Patients undergoing bariatric surgery followed by a total joint All other insurance 309 (93.6) 967 (95.1)
replacement (THA or TKA) were identified. If a patient had Ever Medicaid 21 (6.4) 50 (4.9)
more than one TJA following bariatric surgery, then only the
OBES SURG (2018) 28:1395–1401
respiratory failure, cerebrovascular event, urinary tract infec-
tion, blood transfusion, cardiac complications, peripheral vas-
cular disease, respiratory complications, gastrointestinal com-
plications, gastrointestinal complications, pneumonia, acute
renal failure, acute cholecystitis, central nervous system prob-
lems, hematoma/seroma, wound dehiscence, postoperative in-
fection, or postoperative anemia.
Statistical Methods
Multivariable logistic regression models were applied to com-
pare the likelihood of a complication or readmission following
TJA for varying time periods between bariatric surgery and
TJA. THA and TKA patients were assessed separately. Time
between bariatric surgery and TJA was calculated in months,
and grouped into categories of 0–6 months, 7–12 months, 13–
18 months, 19–24 months, and 25 months or more. The models
were adjusted for age at time of bariatric surgery (< 50, 50–59,
60–69, and 70+ years), sex, race (white, black, other/un-
known), ethnicity (non-Hispanic, Hispanic), and insurance sta-
tus (Medicaid at either admission, all other insurance). Odds
ratios (OR) and 95% confidence intervals (CI) are reported. All
analyses were conducted in SAS v9.3 (Cary, NC).
Results
There were 330 cases of bariatric surgery followed by a THA
and 1017 cases followed by a TKA. Most patients were between
50 and 59 years old (46.4% of THA cohort; 47.0% of TKA
cohort). Patients undergoing THAwere between 22 and 77 years
old (median 56 years); patients undergoing TKA were between
26 and 86 years old (median 57 years). A majority of patients
were female (69.4% THA; 76.4% TKA), white (84.5% THA;
82.2% TKA), and non-Hispanic (90.0% THA; 86.6 TKA).
Fewer than 10% of patients in both cohorts had Medicaid at
either surgical encounter. The largest proportion of TKAs oc-
curred more than 2 years following bariatric surgery (37.2%),
followed by 7–12 months (19.7%), 13–18 months (19.4%), 19–
24 months (14.2), and zero to 6 months (9.6). Time between
bariatric surgery and THA was evenly distributed across all 6-
month intervals following bariatric surgery (Table 1).
90-Day Complications
Pneumonia, acute renal failure, acute cholecystitis, and central
nervous system problems were removed from the composite
outcome because they did not occur in our cohort of patients.
There was no association found between time of bariatric sur-
gery and THA or TKA and 90-day complications in the mul-
tivariable logistic regression analyses. Female patients were
more likely to have a complication than male patients in the
THA (OR 1.82, 95% CI 1.10, 3.00) and TKA (OR 1.56, 95%
1397
CI 1.12, 2.17) cohorts. Age, race, ethnicity, and insurance
were not significantly associated with likelihood of a compli-
cation at 90 days for either surgery.
90-Day Readmission
Patients undergoing THA more than 6 months after bariatric
surgery were significantly less likely to have a 90-day read-
mission for any cause compared to patients undergoing THA
within 6 months after bariatric surgery. No associations were
found between age, sex, race, ethnicity or insurance status,
and readmission after THA. Among TKA patients, there was
no association found between time between surgeries and re-
admission. Age, sex, race and insurance were also not associ-
ated with readmission following TKA. However, non-
Hispanic patients were twice as likely to have a readmission
as Hispanic patients (OR 2.02, 95% CI 1.07, 3.81; Table 2).
Discussion
Bariatric surgery continues to be a popular treatment option
for inducing weight loss in morbidly obese patients, especially
as the prevalence of clinically severe obesity is increasing at a
disproportionately high rate [16]. In addition to its effects on
weight reduction, bariatric surgery also helps improve chronic
medical problems such as diabetes and sleep apnea, which
helps lower the risk of perioperative complications associated
with TJA surgery [17, 18]. Complications lead to increased
costs and hospital resource utilization; Meller et al. reported a
significant increase in total health care resource consumption
for the morbidly and super obese compared to the non-obese
population undergoing TJA [18].
Given the increasing prevalence of obesity in TJA patients
and the push to deliver quality care while controlling costs,
bariatric surgery is offered to many morbidly obese patients
with end-stage arthropathy as a legitimate means for weight
loss, overall health improvement, and improving their
periroperative risk profile. With the increasing fiscal and so-
cietal pressures on the American health care system, delaying
elective TJA surgery with the goal of risk mitigation for these
high-risk patients seems both logical and ethical [19].
Theoretically, increasing the time from bariatric surgery to
elective TJA surgery would increase the benefit of the bariat-
ric procedure by allowing more time for weight loss and im-
provement of associated medical comorbidities. This study
demonstrated a significantly reduced risk of 90-day
readmissions among patients undergoing THA greater than
6 months after bariatric surgery. However, we did not find
an association of time between surgeries and the risk of 90-
day complications for THA patients, or between time from
bariatric surgery to TKA and either 90-day complications or
90-day readmissions. A possible reason for the effect on
1398 OBES SURG (2018) 28:1395–1401

Table 2 Adjusted odds ratios and

95% confidence intervals for THA TKA
complications and readmissions Characteristics 90-day 90-day 90-day 90-day
at 90-days for patients undergoing complications* readmission complications* readmission
bariatric surgery followed by TJA
Months between bariatric surgery and TJA
0–6 months 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
7–12 months 0.75 (0.38, 1.49) 0.36 (0.17, 0.77) 1.30 (0.76, 2.22) 0.93 (0.51, 1.69)
13–18 months 0.75 (0.35, 1.62) 0.21 (0.08, 0.55) 0.99 (0.58, 1.70) 0.73 (0.39, 1.36)
19–24 months 1.56 (0.69, 3.52) 0.33 (0.13, 0.85) 1.31 (0.74, 2.31) 0.68 (0.35, 1.33)
> 24 months 0.67 (0.33, 1.32) 0.32 (0.15, 0.70) 1.30 (0.79, 2.13) 0.71 (0.41, 1.25)
Age
< 50 years 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
50–59 years 0.79 (0.45, 1.39) 0.69 (0.35, 1.36) 1.17 (0.80, 1.71) 1.04 (0.64, 1.67)
60–69 years 1.43 (0.75, 2.72) 1.12 (0.52, 2.37) 1.46 (0.97, 2.20) 1.19 (0.72, 1.97)
70+ years 0.95 (0.26, 3.45) 1.63 (0.39, 6.75) 3.89 (1.88, 8.05) 1.94 (0.85, 4.40)
Sex
Male 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Female 1.82 (1.10, 3.00) 0.66 (0.37, 1.16) 1.56 (1.12, 2.17) 0.74 (0.51, 1.07)
Race
White 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Black 1.53 (0.67, 3.50) 1.04 (0.37, 2.92) 1.07 (0.67, 1.71) 1.33 (0.78, 2.29)
Other/unknown 0.81 (0.31, 2.11) 0.38 (0.10, 1.46) 1.06 (0.65, 1.75) 0.96 (0.49, 1.88)
Ethnicity
Hispanic 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
Non-Hispanic 0.85 (0.37, 1.95) 0.87 (0.32, 2.39) 1.00 (0.66, 1.54) 2.02 (1.07, 3.81)
Insurance
Ever Medicaid 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference)
All other insurance 1.81 (0.67, 4.86) 0.60 (0.21, 1.74) 0.72 (0.40, 1.31) 0.73 (0.35, 1.51)

*Complications refer to complications that occurred at time of total joint arthroplasty

readmission rates was observed for THA patients, and not for
TKA patients, may be that there is more subcutaneous fat
surrounding the hip. The thickness of peri-incisional subcuta-
neous fat has been correlated with complications after cervical
spine and cardiac surgery [20–22], so it can be inferred that
weight loss after bariatric surgery would be most likely to
affect areas of the body with more subcutaneous fat.
Although our data suggest that waiting more than 6 months
after bariatric surgery before undergoing TJA, further studies
are needed to be able to make a definitive recommendation on
the optimal timing for TJA following bariatric surgery.
There are several potential explanations for our results.
First, the time course of patient response to bariatric surgery
is unpredictable, and subjective factors that contribute to an
individual’s response are not captured in an administrative
database. Golomb et al. found that the percentage of excess
weight loss (%EWL) and rates of partial and complete remis-
sion of type 2 diabetes mellitus were significantly lower with
increased time from laparoscopic sleeve gastrectomy (LSG)
[10]. Additionally, the type of bariatric surgery, restrictive, or
malabsorptive, also affects the observed postoperative weight
loss and metabolic changes. Previous studies have shown that
the metabolic benefits of laparoscopic Roux-en-Y gastric by-
pass (LRYGB)—a malabsorptive procedure—are apparent
before substantial weight loss occurs, while weight loss occurs
before metabolic changes after restrictive procedures such as
LSG [23, 24]. Comparing restrictive and malabsorptive pro-
cedures, Shoar et al. found that LRYGB produced greater
long-term weight loss than LSG, though no difference was
observed in the rate of reduction of comorbidities [25]. TJA
candidates who are referred to bariatric surgeons for consulta-
tion should be made aware of the differences in time to desired
postop outcome (weight loss, comorbidity improvement) that
are associated with the chosen procedure, the severity of their
chronic medical problems [10], and their age [10, 26]. The
amount of excess weight prior to surgery has not been shown
to be correlated with changes in obesity-related comorbidity
status, further illustrating the multifactorial nature of each pa-
tient’s response to bariatric surgery.
There are several limitations to this study, mostly related to
the database characteristics. First, we were not able to include
a subgroup analysis based on the type of bariatric procedure
OBES SURG (2018) 28:1395–1401 1399

performed, restrictive or malabsorptive, because the informa- Conclusion

tion was not available in our database. Secondly, patient BMI
was not consistently reported in the database, and we were
unable to include this information in our analysis. Thirdly,
we did not have any information available regarding the nu-
tritional status of our patients, which may have provided more
information on observed complication rates. Additionally, our
analysis was not limited to patients who underwent bariatric
surgery specifically for medical optimization after being indi-
cated for TJA, which may make for a more diverse cohort
because we included any and all bariatric surgery prior to
TJA. Our analysis was also limited by the fact that our data-
base consists of patients within a single state, and includes
only patients who had both procedures, bariatric surgery and
TJA, within the defined time period of the study. Despite these
limitations in sample size, our study reports on one of the
largest cohorts of TJA patients who have also undergone bar-
iatric surgery. Finally, our stratification of patients by time
from bariatric procedure to TJA was somewhat arbitrary, as
there have been no studies published previously that explicitly
define the expected time course for weight and metabolic
changes after bariatric surgery. The strengths of this
population-based database are that it includes all payer data
for the entire diverse state of California, thereby giving us an
opportunity to evaluate trends on a substantially sized cohort.
Our retrospective study did not show that increasing the
time from bariatric surgery to arthroplasty had any effect
on perioperative complications for both TKA and THA.
Our analyses did show a reduced rate of 90-day readmis-
sion for THA, but not for TKA. Based on our results, we
are unable to make a recommendation on the optimal time
for TJA surgery after bariatric surgery. The value of bar-
iatric surgery as part of preoperative medical optimization
may lie in the nature of the metabolic changes, rather than
the magnitude of weight lost. Further studies are needed to
better characterize the temporal relationship of bariatric
and arthroplasty surgeries.
Compliance with Ethical Standards:
Conflict of Interest Dr. Schwarzkopf reports grants and personal fees
from Smith & Nephew, personal fees from Intellijoint. Ms. Lavery reports
no relevant conflicts of interest. Dr. Hooper reports no relevant conflicts
of interest. Dr. Parikh reports no relevant conflicts of interest. Dr. Gold
reports no relevant conflicts of interest.
Ethical Approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.

Appendix

Table 3 ICD-9-CM diagnosis

and procedure codes used to
identify bariatric surgery, total hip
arthroplasty (THA), total knee
arthroplasty (TKA), and select
complications following
THA/TKA
Condition ICD-9 code
Total joint arthroplasty (procedure codes)
Total hip arthroplasty 81.51
Total knee arthroplasty 81.54
Bariatric surgery (procedure codes)
Laparoscopic vertical (sleeve) gastrectomy 43.82
Open and other partial gastrectomy 43.89
High gastric bypass 44.31
Laparoscopic gastroenterostomy [bypass: 44.38
gastroduodenostomy, gastroenterostomy,
gastrogastrostomy, and laproscopic
gastrojujenostomy without gastrectomy NEC]
Other gastroenterostomy without gastrectomy 44.39
[bypass: gastroduodenostomy,
gastroenterostomy, gastrogastrostomy, and
gastrojujenostomy without gastrectomy NOS]
Laparoscopic gastroplasty [banding: silastic 44.68
vertical banding and vertical banded gastroplasty
(VBG)]
Laparoscopic gastric restrictive procedure 44.95
BMI (diagnosis codes)
Overweight and obese V854, 278.x
1400
Table 3 (continued)
Condition
Postoperative complication
Pulmonary embolism [1]
Deep vein thrombosis [1]
Acute myocardial infarction [1]
Respiratory failure [1]
Cerebrovascular accident [1]
Urinary tract infection [1]
Pneumonia [1]
Acute renal failure [1]
Acute cholecystitis [1]
Postoperative blood transfusion [1] Note: paper
provided diagnosis codes of 990.0, but that’s not
right, the procedure code for transfusion is 99.00,
updated based on ICD-9 book (2/8/17)
Central nervous system
Cardiac
Peripheral vascular disease
Respiratory
GI
GU
Hematoma/seroma
Wound dehiscence
Postoperative infection
Postoperative anemia
1. Werner, B.C., et al., Super obesity is an independent risk factor for complications after primary total hip
arthroplasty. J Arthroplasty, 2017. 32(2): p. 402–406
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