A dilemma for patients as well as clinicians!

Let us consider both the cases:

1. Knee replacement before weight loss surgery

Observations:

a) The knee pain would be resolved, and the patient will be able to walk without pain.

b) The benefits of walking as an exercise may be added, but post-operative physiotherapy is so difficult because of the huge excess weight at times.

c) There would be higher risks during anaesthesia due to the comorbidities, surgery may be more difficult due to the excess fat deposition around the knees and thighs. Special care may be needed to minimize wound infection or delayed healing since fat has poor healing properties.

d) The associated conditions in these patients like diabetes, blood pressure, breathing difficulty add to the difficulties before and after the joint replacement.

2. Weight loss surgery or bariatric surgery before the joint and knee replacement

Observations

a) Weight loss surgery adds distinct benefits like weight loss, reversal or control of diabetes, blood pressure and breathlessness.

b) Patient’s pain also reduces significantly because of the weight loss and less pressure on joints. In many patients, the pain totally disappears, and knee replacement can be deferred.

c) Post knee and joint surgery their movements on recommended physiotherapy exercises also turns easy

However, if a joint replacement is performed after the bariatric and obesity surgery, the surgery is easier and diabetes control reduces the chances of infection.

There has been a known association between genes and obesity.

There are over 50 genes studied which are strongly associated with obesity and there are many more which would be known after further studies. Certain genes are protective and ones with these genes maintain a near-normal weight. On the other hand, certain genes may make someone more prone to obesity. However, there is no need to be helpless. Genes can only predispose to obesity. The other environmental factors like lifestyle, dietary pattern, and choices, activity grade, etc. can add fuel to the genetic tendency and induce obesity.

It is known that there are some genetic syndromes that can lead to obesity due to the defect or absence of certain hormones. These are purely genetic forms of obesity and fortunately rare.

One example of a boy I witnessed had leptin deficiency. Those with leptin deficiency by birth have uncontrolled hunger because of the lack of the hormone and the child continues to demand food all the time and eventually succumbs to obesity. What can be learned from this is, if you have excess/ uncontrolled hunger, it could be because of the imbalance of certain hormones, known or unknown. Such a person should seek an opinion from a bariatric physician.

Those who have a history of obesity in families have a higher incidence of severe obesity as well as associated disorders like diabetes, heart disease, etc. Even though genes do play a role in this, they are not the primary or the only reason for this type of obesity. Fortunately, bariatric surgery and certain medications work well in such forms of obesity with strong family tendency.