“I Often Feel Conflicted in Denying Surgery”: Perspectives of Orthopaedic Surgeons on Body Mass Index Thresholds for Total Joint Arthroplasty

Abstract

Background: Use of a patient body mass index (BMI) eligibility threshold for total joint arthroplasty (TJA) is controversial. A strict BMI criterion may reduce surgical complication rates, but over-restrict access to effective osteoarthritis (OA) treatment. Factors that influence orthopaedic surgeons’ use of BMI thresholds are unknown. We aimed to identify and explore orthopaedic surgeons’ perspectives regarding patient BMI eligibility thresholds for TJA. Methods: A cross-sectional, online qualitative survey was distributed to orthopaedic surgeons who conduct hip and/or knee TJA in the United States. Survey questions were open-ended, and responses were collected anonymously. Survey data were coded and analyzed in an iterative, systematic process to identify predominant themes. Results: Forty-five surveys were completed. Respondents were 54.3 ± 12.4 years old (range, 34 to 75 years), practiced in 22 states, and had 21.2 ± 13.3 years (range, 2 to 44 years) of surgical experience. Twelve factors influencing BMI threshold use by orthopaedic surgeons were identified: (1) evidence interpretation, (2) personal experiences, (3) difficulty of surgery, (4) professional ramifications, (5) ethics and biases, (6) health-system policies and performance metrics, (7) surgical capacity and resources, (8) patient body fat distribution, (9) patient self-advocacy, (10) control of decision-making in the clinical encounter, (11) expectations for demonstrated weight loss, and (12) research and innovation gaps. Conclusions: Multilevel, complex factors underlie BMI threshold use for TJA eligibility. Addressing identified factors at the patient, surgeon, and health-system levels should be considered to optimally balance complication avoidance with improving access to life-enhancing surgery. Clinical Relevance: This study may influence how orthopaedic surgeons think about their own practices and how they approach patients and consider surgical eligibility.