A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
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20 The Medical Student Notebook Bariatric Times • February 2017 In a Chinese cohort assessing 10 patients who underwent LAGB to t reat morbid obesity, knee pain resolved in the two patients that reported initial knee pain problems over a median follow-up period of 12 months. 26 V ertical Banded Gastroplasty. Although no longer commonly performed due to the advent of newer and more effective weight loss surgery procedures, in 1990, McGoey e t al demonstrated a reduction in reported knee pain from 57 percent to 14 percent in a cohort of 105 consecutive patients undergoing vertical banded gastroplasty. 27 M ixed Groups. Studies examining the effect of weight loss surgery, without delineating surgery type, have also shown promise. In a study of 24 patients undergoing weight loss surgery, including RYGB, gastric banding, and sleeve gastrectomy, patients showed statistically significantly improved scores in knee pain, knee stiffness, and physical function in both activities of daily living and sports and recreation when assessed using the WOMAC index and the Knee Injury and Osteoarthritis Outcome Score at six months follow-up. 28 In a 2012 study following 25 patients that either underwent RYGB or LAGB three months post-surgery, the severity of knee pain decreased by 34 percent, walking speed increased by 15 percent, and step length increased by 4.8cm. These differences were all statistically significant when compared to a nonsurgical control group, demonstrating the potential benefits weight loss surgery could provide symptomatically as well as biomechanically. 29 DISCUSSION The link between knee osteoarthritis and obesity has been well established in the medical literature. However, while the effects of both nonoperative and operative bariatric weight loss surgery have been shown to improve knee pain, function, and biomechanics, the quality of data in surgical management currently lags behind that of nonoperative options. While multiple randomized control trials demonstrate the benefits of diet and exercise on knee symptoms, surgical outcomes are currently limited to mostly prospective follow-up studies. 8 In addition, no study to date has conducted a randomized control trial assigning patients with obesity with knee osteoarthritis to either nonoperative or operative weight loss m anagement. As a result, direct comparisons between the benefits of nonoperative weight loss and surgical weight loss options on improvement in knee osteoarthritis symptoms c annot currently be made. Future directions in the field would benefit from dedicated assessment into the effect of sleeve gastrectomy, a procedure growing in p opularity, on knee osteoarthritis symptoms. The current available studies took place at times when LAGB and RYGB were more popular. Furthermore, it would be beneficial t o define the relationship between body fat percentage lost after bariatric weight loss surgery and knee osteoarthritis. While this interesting association has been addressed in the nonoperative management literature, currently no weight loss surgery literature addresses the connection between body fat percentage lost through bariatric surgery and its effects on knee osteoarthritis. Improving these areas of research will be beneficial to future bariatric patients as they explore the possibilities of weight loss surgery. ACKNOWLEDGMENT Mr. Yang would like to thank Ayesha Abdeen, MD, FRCSC, for her assistance with reviewing this article. Dr. Abdeen is Instructor, Harvard Medical School; Director of Quality Assurance, Department of Orthopaedic Surgery; Chief, Division of Arthroplasty, Beth Israel Deaconess Medical Center, Boston, Massachusetts. REFERENCES 1. Zhang Y, Jordan JM. Epidemiology of osteoarthritis. Clin Geriatr Med. 2010;26(3):355–369. 2. Weinstein AM, Rome BN, Reichmann WM, et al. Estimating the burden of total knee replacement in the United States. J Bone Joint Surg Am. 2013;95(5):385–392. 3. Suri P, Morgenroth DC, Hunter DJ. Epidemiology of osteoarthritis and associated comorbidities. PM R. 2012;4(5 Suppl):S10–19. 4. Jiang L, Tian W, Wang Y, et al. Body mass index and susceptibility to knee osteoarthritis: a systematic review and meta-analysis. Joint Bone Spine. 2012;79(3):291–297. 5. Messier SP, Gutekunst DJ, Davis C, DeVita P. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum. 2005;52(7):2026–2032. 6 . Richette P, Poitou C, Garnero P, et al. Benefits of massive weight loss on symptoms, systemic i nflammation and cartilage turnover in obese patients with knee osteoarthritis. Ann Rheum Dis. 2 011;70(1):139–144. 7. Bragge T, Lyytinen T, Hakkarainen M, et al. Lower impulsive loadings f ollowing intensive weight loss after bariatric surgery in level and stair walking: a preliminary study. Knee. 2 014;21(2):534–540. 8. Groen VA, van de Graaf VA, Scholtes VA, Sprague S, van W agensveld BA, Poolman RW. Effects of bariatric surgery for knee complaints in (morbidly) obese a dult patients: a systematic review. Obes Rev. 2015;16(2):161–170. 9. Abu-Abeid S, Wishnitzer N, Szold A , Liebergall M, Manor O. The influence of surgically-induced weight loss on the knee joint. Obes S urg. 2005;15(10):1437–1442. 10. Losina E, Walensky RP, Reichmann WM, et al. Impact of obesity and k nee osteoarthritis on morbidity and mortality in older Americans. Ann Intern Med. 2011;154(4):217–226. 11. Zingg M, Miozzari HH, Fritschy D, Hoffmeyer P, Lubbeke A. Influence of body mass index on revision rates after primary total knee arthroplasty. Int Orthop. 2016;40(4):723–729. 12. Mulhall KJ, Ghomrawi HM, Mihalko W, Cui Q, Saleh KJ. 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Obesity and the role of bariatric surgery in the surgical management of osteoarthritis of the hip and knee: a review of the literature. Surg Obes Relat Dis. 2016. pii: S1550-7289(16)30697-9. 22. Lyytinen T, Liikavainio T, Paakkonen M, Gylling H, Arokoski JP. Physical function and properties of quadriceps femoris muscle after bariatric surgery and subsequent weight loss. J Musculoskelet Neuronal Interact. 2013;13(3):329–338. 23. Julia C, Ciangura C, Capuron L, et al. Quality of life after Roux-en-Y gastric bypass and changes in body mass index and obesity-related comorbidities. Diabetes Metab. 2013;39(2):148–154. 24. Hooper MM, Stellato TA, Hallowell PT, Seitz BA, Moskowitz RW. Musculoskeletal findings in obese subjects before and after weight loss following bariatric surgery. Int J Obes (Lond). 2007;31(1):114–120. 25. Korenkov M, Shah S, Sauerland S, Duenschede F, Junginger T. Impact of laparoscopic adjustable gastric banding on obesity co-morbidities in the medium- and long-term. Obes Surg. 2007;17(5):679–683. 26. Wong SK, So WY, Yau PY, et al. Laparoscopic adjustable gastric banding for the treatment of morbidly obese patients: early outcome in a Chinese cohort. Hong Kong Med J. 2005;11(1):20–29. 27. McGoey BV, Deitel M, Saplys RJ, Kliman ME. Effect of weight loss on musculoskeletal pain in the morbidly obese. J Bone Joint Surg Br. 1990;72(2):322–323. 28. Edwards C, Rogers A, Lynch S, et al. The effects of bariatric surgery weight loss on knee pain in patients with osteoarthritis of the knee. Arthritis. 2012;2012:504189. 29. Vincent HK, Ben-David K, Conrad BP, Lamb KM, Seay AN, Vincent KR. Rapid changes in gait, musculoskeletal pain, and quality of life after bariatric surgery. Surg Obes Relat Dis. 2012;8(3):346–354. FUNDING: No funding was provided. FINANCIAL DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article. ADDRESS FOR CORRESPONDENCE: Brian W. Yang, E-mail: byang@bidmc.harvard.edu In a recent meta-analysis, a five-unit increase in body mass index (BMI) was associated with a 35-percent increased risk of knee osteoarthritis. 4 I ncreased weight places mechanical increased strain on the knee joint. Data have shown that each p ound of weight lost corresponds to a four-fold reduction in force applied to the knee joint. 5