When obesity prevents joint replacement

The last time Alicia Kline walked unassisted was in January 2021. She is in constant pain from hip arthritis and uses a walker and a wheelchair.

The problem is her obesity — her body mass index, or BMI, is over 50. And for someone like Kline, 54, of Reading, Pennsylvania, finding a doctor who is willing to give her a joint replacement that may ease the pain can be a near-impossible task.

Dilemmas like hers are roiling orthopedic medicine as obesity levels soar and with them arthritis. What should orthopedists do when confronted with patients whose BMI is very high?

While the science of body mass index is frequently criticized, doctors say the risks of operating on patients with BMIs that fall in the upper ranges of obesity can be dire, including infections deep in the prosthetic joint that can lead to amputations and even death. And the risks escalate as a patient’s BMI increases.

Professional organizations — the American Academy of Orthopedic Surgeons and the American Association of Hip and Knee Surgeons — do not have firm BMI cutoffs for operations, but orthopedists have their own.

Less than half of orthopedic surgeons in a survey published last year said they would operate on a patient with a BMI over 40 — more than 22 million American adults fell into that category in 2017-18. Only 11% would operate on one of the 3.9 million Americans with a BMI over 50. And patients with a BMI over 55 would be rejected almost everywhere. Just 3% of U.S. orthopedists would operate.

And even if a doctor is willing to operate, insurers often refuse to pay. Hospitals also may turn away these patients, who tend to need longer stays and more care and are considered money losers.

The result, said Dr. Nathanael Heckmann of the University of Southern California, is that “whole populations are being denied orthopedic care.”

Patients suspect the stigma of obesity plays a role.

“It’s just a blanket, ‘You weigh too much, therefore, you don’t get this,’” said Lynn Rubinett, 66, of Austin, Texas, who says she fought for more than a year before she could get a hip replacement. Her BMI was 43.

The new obesity drugs such as Wegovy and Zepbound might help some, but they would be insufficient for many. For example, a woman who is 5 feet 5 inches tall and has a BMI of 50 would have to lose 20% of her weight to get to a BMI of 40 — something few can do, even with the new drugs.

At issue is an ethical quandary: Is it OK to replace the joints of patients who are severely obese? And who should make that decision?

Patients say doctors often hold the outdated assumption that, if patients tried, they could lose weight.

One surgeon quipped to Rubinett that “people gain weight back after their hip replacement because they can get up and walk to the fridge again.’”

That joke, added Rubinett, reveals “a deep lack of compassion or understanding about how truly complex and difficult it is to sustainably shrink a body that carries 50 to 100 or more extra pounds.”

Doctors say there is a real struggle to balance patients’ needs with their commitment to medical ethics.

That includes Dr. Yale Fillingham of the Rothman Orthopaedic Institute in Philadelphia, who is developing updated guidelines for the American Association of Hip and Knee Surgeons.

“It’s a difficult topic,” he said. “There are a lot of nuances and different viewpoints that go into saying a BMI cutoff is a good thing or a bad thing.”

Surgeons say they realize that the presence or absence of other chronic diseases, like diabetes, can affect risk. But, they note, 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 people.

“When you look at the survivorship of someone who has an infection and how morbid and deadly the infection is, a lot of surgeons would rather tell the patient, ‘I’m sorry, I can’t help you,’ than feel responsible for devastating outcomes,” Fillingham said.

Dr. Charles P. Hannon, an orthopedic surgeon at the Mayo Clinic in Rochester, Minnesota, does not have a strict BMI cutoff but says patients with high BMIs have to understand what they may be facing. The risk of an infection maybe 10% or less, “but if it happens to you, it is 100%,” he said.

Hannon said a patient recently came to him after another doctor replaced his hip. The man’s wound did not heal, and he developed an infection deep within his joint.

“We are trying to save his leg,” Hannon said.

For Kline, nothing — not even death, she says — can be worse than the life she is living.

Her problems began in 2012, when she was 42 and her left hip began hurting so badly she couldn’t sleep. Her doctor’s diagnosis: is osteoarthritis. His prescription: Lose weight.

Soon, she couldn’t walk. She had been swimming since 2006, but one day early in 2021, she was in too much pain for that.

Shortly after that awful day, Kline went to a local orthopedist in private practice.

To her surprise, she said, he never mentioned her weight. Instead, he offered to replace both hips, starting with the left one.

He operated in April 2021. Her BMI was 45. A day later, she was discharged from the hospital, but her incision leaked for 20 weeks and her left hip hurt so much she couldn’t walk.

She went to the Rothman Institute for a second opinion and saw Fillingham.

That pain? It was from a deep infection. He had to remove her prosthetic hip and put in a temporary implant while her infection cleared. She was in the hospital for a month and took intravenous antibiotics for 55 days.

Three months later, Fillingham gave her a new left hip. She was hospitalized for four days with no complications.

But her right hip hurt so much that she could not walk. Her BMI shot up to 50.

Fillingham was unable to help. His orthopedic practice allows joint replacement for a patient who had an infection after an earlier procedure. However, it will not allow primary joint replacement for patients with a BMI over 50. Kline’s is now 59.

Fran Ryan of Reno, Nevada, was ready to give up on finding a doctor who would give her a new hip. With a BMI of 41, she was told by surgeons she was simply too fat.

“I was in my early 50s, and I couldn’t walk,” she said. “I have three kids — we walk and we hike.”

But she couldn’t do that anymore. She got a handicapped sticker for her car after a physiatrist told her that even walking the length of Costco was “too much walking.” And she knew it was — that short walk left her in intense pain.

Finally, she found a surgeon, Dr. Derek Amanatullah, at Stanford University — a four-hour drive from her home — who agreed to operate.

“He made me feel like a person,” she said. “Other doctors take that away — it doesn’t matter if you are in pain because you’re fat.”

That was in August.

“My surgery was robotically assisted and was outpatient,” she said. She had no complications.

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Her son was married on Sept. 16.

“All I wanted to do was to be able to dance with him at his wedding,” Ryan said. She did, even though, she said, “I had to use my cane.

“My life is so dramatically improved,” she added, though she is not completely back to normal. “I lost so much muscle tone from not being able to walk,” she explained.

“But,” she said, “I had to be tenacious to keep looking for options after hitting brick walls.

“It is not lost on me that not everyone has those resources,” Ryan said.

For those with higher BMIs, the search for help can be fruitless.

Janet Daniels, 56, of Alexandria, Virginia, has had obesity since she was 8. And no diet or exercise program has helped control her weight. Her BMI is 61.3. Over and over, she was told no one would operate on her.

She recently tried a new orthopedist, the fifth so far. When he saw her X-rays, he exclaimed that she was “bone on bone in both knees.”

But he, too, refused to do the surgery.

She shot back, “you’re the umpteenth orthopedist who has told me, ‘You’re fat. You have to suffer.’”

On her way out, he handed her the card of a nutritionist.

Kline finally found a doctor willing to replace her right hip, but he wants her to lose 30 pounds.

“He would not even schedule a follow-up appointment with me,” Kline said. “He told me to call back when I lost the 30 pounds.”

She has been trying since April and has been taking Wegovy for a month. But, so far, she hasn’t lost enough weight.

“I can’t live like this,” Kline said.

Heckmann understands. Though he has not treated Kline, he sees patients with very high BMIs on a regular basis. And he sometimes says yes. But he would refuse a patient like her.

Someone who had an infection in one hip is much more likely to have another infection if he replaces the other hip. And congestive heart failure makes the surgery even more risky. He’s afraid an operation might kill her.

“I have a moral obligation to not harm,” Heckmann said. “It goes against my moral fiber to do something that is prohibitively high risk.”

This article originally appeared in The New York Times.