While the American Academy of Orthopedic Surgeons and the American Association of Hip and Knee Surgeons do not have hard body-mass index cutoffs for operating on patients, many providers have their own self-imposed cutoffs, according to a Sept. 4 report from The New York Times.
In a survey published last year, less than half of orthopedic surgeons said they would operate on a patient with a BMI over 40. However, in 2018 more than 22 million American adults fell into that category.
Only 11% of surgeons would operate on one of the 3.9 million Americans with a BMI over 50, while just 3% of U.S. orthopedists would operate on a patient with a BMI over 55.
"Obese patients bleed more. They have more wound healing issues. More infections. More general complications. They have more reoperations. This occurs even in the most skilled hands. I've been a spine surgeon for 23 years and done more than 10,000 cases, but BMI patients [with BMI greater than 40] have more complications that I cannot control. It's operator independent," Lali Sekhon, MD, a neuro and spine surgeon at Reno (Nev.) Orthopedic Center, told Becker's.
For high-BMI patients, not getting joint replacement care can also result in harmful side effects. Some, like Alicia Kline, 54, of Reading, Pa., have been unable to walk unassisted since January 2021.
Ms. Kline said she is in constant pain from hip arthritis and uses a walker and a wheelchair. Since her BMI is over 50, she has been unable to find a doctor who is willing to give her a joint replacement.
While some practices are making an effort to make joint and spine care accessible to overweight patients, other factors, including payer reimbursements, also make the procedures difficult.
Insurers often refuse to pay for high-obesity patients, and hospitals also may turn away these patients, who tend to need longer stays and more care and are considered money-losers, according to the Times.
New weight loss medications, including Wegovy and Zepbound, may be able to help patients lose enough weight to undergo operations. However, the amount of weight loss they provide may 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 achieve a BMI of 40; Wegovy's average weight loss is 15% after 68 weeks.
While some patient advocates believe stigma against obesity plays a role in some surgeons' decisions not to operate on high-BMI patients, there are several medical risks involved as well.
Some of the dire risks include a higher risk of infections in the prosthetic joint, which can lead to amputations or death.
"I have a moral obligation to do no harm," Nathanael Heckmann, MD, an assistant orthopedic surgery professor at the Keck School of Medicine of USC, told the Times. "It goes against my moral fiber to do something that is prohibitively high risk."