ORIGINAL ARTICLE
Obesity Is Associated With More Complications and Longer
Hospital Stays After Orthopaedic Trauma
Benjamin R. Childs, BS,* Nickolas J. Nahm, MD,* Andrea J. Dolenc, BS,* and Heather A. Vallier, MD*
Objective: The objective of this study was to characterize relation-
ships between obesity and initial hospital stay, including complica-
tions, in patients with multiple system trauma and surgically treated
fractures.
Design: Prospective, observational.
Setting: Level 1 trauma center.
Patients: Three hundred seventy-six patients with an Injury
Severity Score greater than 16 and mechanically unstable high-
energy fractures of the femur, pelvic ring, acetabulum, or spine
requiring stabilization.
Main Outcome Measurements: Data for obese (body mass
index $ 30) versus nonobese patients included presence of pneumo-
nia, deep vein thrombosis, pulmonary embolism, infection, organ
failure, and mortality. Days in ICU and hospital, days on ventilator,
transfusions, and surgical details were documented.
Results: Complications occurred more often in obese patients
(38.0% vs. 28.4%, P = 0.03), with more acute renal failure (5.70%
vs. 1.38%, P = 0.02) and infection (11.4% vs. 5.50%, P = 0.04).
Days in ICU and mechanical ventilation times were longer for obese
patients (7.06 vs. 5.25 days, P = 0.05 and 4.92 vs. 2.90 days, P =
0.007, respectively). Mean total hospital stay was also longer for
obese patients (12.3 vs. 9.79 days, P = 0.009). No signicant differ-
ences in rates of mortality, multiple organ failure, or pulmonary
complications were noted. Medically stable obese patients were
almost twice as likely to experience delayed fracture xation due
to preference of the surgeon and were more likely to experience
delay overall (26.0% vs. 16.1%; P = 0.02). Mean time from injury
to xation was 34.9 hours in obese patients versus 23.7 hours in
nonobese patients (P = 0.03).
Conclusions: Obesity was noted among 42% of our trauma
patients. In obese patients, complications occurred more often and
hospital and ICU stays were signicantly longer. These increases are
Accepted for publication February 26, 2015.
From the *Department of Orthopaedic Surgery, MetroHealth Medical Center,
Case Western Reserve University, Cleveland, OH.
Presented as a poster at the Annual Meeting of the Orthopaedic Trauma
Association, October 2013, Phoenix, AZ.
The authors report no conict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journals Web site (www.jorthotrauma.com).
The MetroHealth IRB approved this study.
Reprints: Heather A. Vallier, MD, Department of Orthopaedic Surgery, 2500
MetroHealth Drive, Cleveland, OH 44109 (e-mail: hvallier@metrohealth.org).
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likely to be associated with greater hospital costs. Surgeon decision
to delay procedures in medically stable obese patients may have
contributed to these ndings; denitive xation was more likely to
be delayed in obese patients. Further study to optimize the care of
patients with increased body mass index may help to improve
outcomes and minimize additional treatment expenses.
Key Words: obesity, fracture, xation, complication, BMI
Level of Evidence: Prognostic Level II. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2015;29:504509)
INTRODUCTION
In the United States, over one-third of adults (35.7% in
2010) and one-sixth of children and adolescents (16.9% in
2010) are obese.13 Recently, heightened awareness of the role
of obesity in heart disease, diabetes, and asthma has been seen.
However, there has been less research on effects of obesity in
injured patients. Recent studies have indicated that obese
trauma patients are more likely to need mechanical ventilation,
develop multiple organ failure (MOF), and spend more time in
the ICU.47 Others have also cited increased mortality, length of
hospital stay, overall complication rate, and infections in obese
patients.810 Specic challenges and complications after muscu-
loskeletal injury have also been associated with obesity, includ-
ing difculty in sacral imaging,11 early failure after xation of
syndesmosis injuries,12 difculty reducing acetabular frac-
tures,13 and more complications after surgical treatment of pel-
vic ring injuries.14 Such issues are likely to generate substantial
additional costs of care.
Our purpose was to study the experience of a major
urban level 1 trauma center to determine the frequency of
complications among multiply injured obese patients treated
surgically for unstable axial fractures. We hypothesized that
obesity would be associated with more complications during
the initial hospital course and that obesity would result in
longer ICU and hospital stays.
PATIENTS AND METHODS
Data were prospectively collected for 30 months for all
376 skeletally mature patients surgically treated for a high-
energy fracture of the proximal or diaphyseal femur (n = 165),
pelvic ring (n = 72), acetabulum (n = 53), or spine (n = 104).
Patients without an associated major injury to another body
system were excluded. All patients had an Injury Severity
Score (ISS) of 16 or higher.
J Orthop Trauma  Volume 29, Number 11, November 2015
 J Orthop Trauma  Volume 29, Number 11, November 2015 Effects of Obesity on Hospital Course

Patients with a body mass index (BMI) of 30 or greater
were considered obese. Those with a BMI less than 30 were
considered nonobese. Age, gender, injury characteristics,
laboratory values, hospital stay, length of mechanical venti-
lation, and transfusion records were obtained from electronic
hospital records.
Complications were adjudicated by a panel of physi-
cians not involved in other data collection or analysis. Deep
venous thrombosis (DVT) was diagnosed by positive duplex
ultrasound proximal to the knee. Pulmonary embolism was
diagnosed by computed tomography. Pneumonia was
dened as culture-positive sputum with new persistent
inltrate on chest radiograph, a temperature .388C, and
a white blood cell count .10,000/mL.15 Acute respiratory
distress syndrome was dened as an acute onset of bilateral
inltrates on chest radiography and a PaO2:FiO2 ratio of less
than 200 mm Hg for 4 consecutive days in the absence of
cardiogenic pulmonary edema.16 Acute renal failure (ARF)
was dened as 50% increase in creatinine from baseline
level.17 Sepsis was dened as infection manifested by at
least 2 of the following: temperature .388C or ,368C, heart
rate .90 beats per minute, respiratory rate .20 breaths
per minute or PaCO2 , 32 mm Hg, and white blood cell
count .12,000/mm3, ,4000/mm3, or .10% immature
(band) forms.18 MOF was dened as failure of 2 or more
organ systems.19
Independent samples t tests were used to compare means
of continuous and ordinal variables between obese and non-
obese patients. P values less than 0.05 were considered to rep-
resent a signicant difference. For variables with Levene Test
for Equality of Variances greater than 0.05, equal variance was
not assumed. Pearson x2 test less than 0.05 was considered to
represent a signicant difference in categorical variables
between obese and nonobese patients. Multivariate regression
techniques were used to control for age and American Society
of Anesthesiologists (ASA) score. All analyses were performed
in SPSS (version 21.0; IBM Corporation, Armonk, NY).
RESULTS
Three hundred seventy-six patients (264 men and 112
women) were treated for 394 fractures of interest, and 158 of
them (42.0%) had a BMI greater than 30 and were considered
obese (Table 1). The mean BMI for the obese group and the
nonobese group were 36.8 6 6.8 (range, 30.062.9) and 24.7 6
3.2 (range, 16.429.9), respectively (P , 0.0001). Thirty-
seven patients had BMI .40 (9.8%). Female patients were
more likely to be obese: 38.0% of obese patients were women
versus 26.1% of nonobese patients (P = 0.003). Mean age of
obese patients was also higher than nonobese patients (44.7 6
16.3 years vs. 36.4 6 16.5 years; P , 0.001). Mean ISS was
28.1 6 12.7 for obese patients and 26.1 6 11.4 for nonobese
patients (P = 0.12). Obese patients were twice as likely to
have diabetes mellitus (P , 0.0001).
Injuries to other body systems are listed in Table 1. No
differences were seen in the presence or severity of injuries to
the head, chest, or abdomen, between obese and nonobese
patients. Fractures of interest are also noted in Table 1. Non-
obese patients were more likely to be treated for femoral
fractures, occurring in 48.2% versus 38.0% (P = 0.049).
There was also a trend for obese patients to be more likely
to be treated for pelvic ring injuries, occurring in 23.4% ver-
sus 16.1% (P = 0.07).
Time from the injury until denitive xation of the
fractures of interest was studied (Table 2). Mean time to
xation for obese patients was 34.9 hours after injury versus
23.7 hours for nonobese patients (P = 0.03). In other words,
obese patients waited a mean of 47% longer to have their

TABLE 1. Demographic and Injury Information

All patients (N = 376), n (%) Obese (N = 158), BMI 30, n (%) Nonobese (n = 218) P
Female 112 60 (38.0) 52 (23.9) 0.003
Male 264 98 (62.0) 166 (76.1)
Mean age (years) 39.9 6 16.9 44.7 6 16.3 36.4 6 16.5 ,0.001
Mean ISS 26.9 6 12.0 28.1 6 12.7 26.1 6 11.4 0.12
Mean GCS 13.6 6 3.1 13.7 6 3.1 13.6 6 3.1 NS
Mean ASA 2.84 6 0.84 3.00 6 0.78 2.73 6 0.87 0.002
Diabetes mellitus 113 (30) 67 (42) 46 (21) ,0.0001
Tobacco usage 192 (51) 77 (49) 115 (53) NS
COPD 22 (5.9) 10 (6.3) 12 (5.5) NS
Alcohol abuse 31 (8.2) 14 (8.9) 17 (7.8) NS
Abdominal injury 103 (27.4) 48 (30.4) 55 (25.2) 0.27
Chest injury 226 (60.1) 100 (63.3) 126 (58.0) 0.31
Head injury 220 (58.5) 92 (58.2) 128 (58.7) 0.93
Pelvis ring injury 72 37 (23.4) 35 (16.1) 0.073
Acetabulum fracture 53 25 (15.8) 28 (12.8) 0.41
Femur fracture 165 60 (38.0) 105 (48.2) 0.049
Spine fracture 104 40 (25.3) 64 (29.4) 0.39
P values comparing obese and nonobese patients are shown. The presence of surgically treated fractures of interest and the presence of associated injuries are indicated.
GCS, glasgow coma scale; COPD, chronic obstructive pulmonary disease.

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 Childs et al J Orthop Trauma  Volume 29, Number 11, November 2015

TABLE 2. Surgical Timing and Duration

All patients (N = 376), n (%) Obese (N = 158) BMI 30, n (%) Nonobese (N = 218), n (%) P
Timing to xation (hrs) 28.4 6 43.7 34.9 6 60 23.7 6 25 0.030
Number with delayed xation 76 (20.2) 41 (26.0) 35 (16.1) 0.018
Length of surgery (hr:min) (hr:min) 3:20 6 2:02 3:38 6 2:13 3:08 6 1:52 0.025
(hr:min)
Transfusions (units) 5.8 6 10 6.6 6 8.5 5.2 6 11 0.16
Delayed xation was dened as more than 36 hr after injury, occurring in 20% of all patients. P values comparing obese and nonobese patients are shown.

fractures stabilized. Reasons for all surgical delays were
noted. Seventy-six of all 376 patients had denitive xation
more than 36 hours after injury (20.2%). Thirty-one of 41
(76%) of the delayed surgeries in obese patients were due
to surgeon choice, whereas 24 of the 35 delays (69%) in
nonobese patients were by surgeon choice (P = 0.02). Mean
timing of fracture xation was not different between obese
and nonobese patients when those due to surgeon choice were
excluded: 19.2 hours for obese patients versus 18.3 for non-
obese (P = 0.67).
Despite no differences in ISS or in injuries to other
body systems, longer hospital stays were observed in obese
patients (see Table, Supplemental Digital Content 1, http://
links.lww.com/BOT/A334), which compares length of stay
and ventilation times in obese and nonobese patients. Obese
patients spent more days in the ICU (7.06 6 9.2 vs. 5.25 6
8.6, P = 0.054), more days on mechanical ventilation (4.92 6
7.8 vs. 2.90 6 6.2, P , 0.01), and more total days in the
hospital (12.3 6 9.5 vs. 9.79 6 8.8, P , 0.01).
A total of 106 patients developed 150 early complica-
tions (Table 3). Obese patients were more likely to have
complications (38.0% vs. 28.4%, P = 0.03). Thirty patients
had soft tissue infections (7.98%), and 6 of them developed
sepsis. Obese patients were more likely to develop infections
(11.4% vs. 5.50%, P = 0.04), with rates of sepsis in 8.28%
versus 4.13% (P = 0.09) for obese versus nonobese patients,
respectively. ARF was signicantly more frequent in obese
patients (5.70% vs. 1.38%, P = 0.02), and there was a trend
toward more DVTs in obese patients (4.43% vs. 1.38%,
P = 0.07). No differences in the rates of pulmonary compli-
cations, MOF, and death were noted between the 2 groups.
Post hoc power analysis revealed our study to be underpow-
ered to identify a difference between obese and nonobese
patients for comparisons of pulmonary complications, MOF,
or mortality, as these would require study of 412, 3644, and
3233 patients, respectively.
Eight patients had early failure of xation (2.1%),
requiring revision surgery. This occurred more often in obese
patients (3.80% vs. 0.92%, P = 0.056). However, rates of
nonunion were not different when the 2 groups were com-
pared. Nonunions occurred overall in 12 patients (3.2%).
We further divided patients into groups of increasing
BMI (Table 4). Obese patients were subdivided into three
BMI groups: 3034.9, 3539.9, and greater than 40. The
frequency of some complications increased as BMI increased
from normal (,25) to overweight (2529.9) and to obese.
This is further depicted in Figure 1. Patients with BMI over
40 also had longer mechanical ventilation times versus nor-
mal BMI patients (5.51 days vs. 2.78, P = 0.02) and a trend
toward longer total length of hospital stay (14.0 days vs. 10.9,
P = 0.08). Mean length of surgery was also an hour longer in
patients with BMI over 40 versus those with normal BMI
(4:03 vs. 3:07, P = 0.02).
Controlling for the signicantly higher mean age of the
obese population, increasing BMI was a signicant predictor
of increased duration of surgery (b = 1.35, t(374) = 2.575, P =
0.01, r2 = 0.02), increased length of hospital stay (b = 0.120,
t(374) = 2.298, P = 0.017, r2 = 0.017), and increased length of

TABLE 3. Complications in Obese and Nonobese Patients

Obese (N = 158) BMI 30, n (%) Nonobese (N = 218), n (%) P
Complication 60 (38.0) 62 (28.4) 0.033
Infection 18 (11.4) 12 (5.50) 0.038
Sepsis 13 (8.28) 9 (4.13) 0.091
DVT 7 (4.43) 3 (1.38) 0.069
PE 3 (1.90) 8 (3.67) 0.31
Pneumonia 16 (10.1) 22 (10.1) 0.99
ARDS 1 (0.63) 6 (2.75) 0.13
ARF 9 (5.70) 3 (1.38) 0.019
MOF 2 (1.27) 1 (0.46) 0.38
Death 8 (5.06) 9 (4.13) 0.67
Implant failure 6 (3.80) 2 (0.92) 0.056
Nonunion 5 (3.16) 7 (3.21) 0.98
Early complications are listed along with complications requiring revision surgery due to implant failure or nonunion, occurring within 6 mo after injury.
ARDS, acute respiratory distress syndrome; PE, pulmonary embolism.

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 J Orthop Trauma  Volume 29, Number 11, November 2015 Effects of Obesity on Hospital Course

TABLE 4. Frequency of Complications, Length of Hospital Stay, Including ICU Days and Time on Mechanical Ventilation, Based
on BMI
Normal BMI ,25 Overweight BMI 2529.9 Obese 1 BMI 3034.9 Obese 2 BMI 3539.9 Obese 3 BMI .40
(N = 107), n (%) (N = 111), n (%) (N = 89), n (%) (N = 32), n (%) (N = 37), n (%)
Any complication 25 (23.3) 30 (27.0) 26 (29.2) 13 (40.6) 12 (32.4)
ARF 0 3 (2.70) 2 (2.25) 3 (9.38) 4 (10.8)
DVT 2 (1.87) 1 (0.90) 2 (2.25) 2 (6.25) 3 (10.8)
Infection 5 (4.67) 7 (6.31) 10 (11.2) 4 (12.5) 4 (10.8)
Sepsis 4 (3.74) 5 (4.50) 5 (5.62) 5 (15.6) 3 (8.11)
Death 1 (0.93) 8 (7.21) 4 (4.49) 1 (3.13) 3 (8.11)
Mean mechanical 2.78 6 5.7 3.03 6 6.8 4.03 6 7.2 6.72 6 9.3 5.51 6 7.7
ventilation days
Mean surgical ICU 5.53 6 8.6 4.97 6 8.7 5.74 6 8.3 10.0 6 11.9 7.69 6 8.2
days
Mean total length of 10.9 6 9.1 8.76 6 8.4 10.8 6 8.6 14.8 6 11 14.0 6 10
hospital stay (d)
Mean surgical duration 3:07 6 1:58 3:10 6 1:46 3:23 6 2:02 3:48 6 2:25 4:03 6 2:26
(hr:min)
Obese patients were divided into 3 groups based on increasing BMI.

time on mechanical ventilation (b = 0.118, t(374) = 2.267, P =
0.024, r2 = 0.026). BMI was not an signicant predictor of
increased time in the ICU (b = 0.085, t(374) = 1.619, P =
0.106, r2 = 0.018).
Binary logistic regression did not show a signicant per
BMI unit increase in the odds of infection (P = 0.181), sepsis
(P = 0.153), pulmonary embolism (P = 0.676), pneumonia
(P = 0.290), acute respiratory distress syndrome (P = 0.496),
MOF (P = 0.512), death (P = 0.200), implant failure (P =
0.176), pulmonary complications (P = 0.306), or complica-
tions (P = 0.148) regardless of age or ASA score. Odds of
developing ARF increased by 7.5% per unit BMI controlled
for ASA score (P = 0.010) or by 7.0% controlled for age (P =
0.023). The odds of developing a DVT increased by 9.1% per
BMI unit controlled for ASA score (P = 0.005) or 10.1%
when controlled for age (P = 0.003). Notably, due to the
effects of multicollinearity, because age is a key determinant
of ASA score, the concurrent adjustment of ASA score and
age is not reported.
DISCUSSION
From 1991 to 1998, the prevalence of obesity in the
United States increased from 12% to 17.9%. This trend was
reected across all states, age groups, education levels, and
sexes.2,20,21 Obesity has continued to climb and is a major
public health issue, as it is widely and credibly linked to
chronic heath conditions including heart disease, diabetes,
and premature mortality.20,22 If current obesity trends and
health care costs continue to progress at the same rate, the
majority of adults in the United States would be obese by
2030, and obesity-related health care costs would double
every decade, reaching 860 billion dollars by 2030.23 These
trends are reected in our study with 42% of our cohort found

FIGURE 1. Frequency of complications

(percent of patients) based on increasing
BMI. Patients with BMI ,25, 2529,
3024, 3540, and .40 are presented.
Editors note: A color image accom-
panies the online version of this article.

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 Childs et al
in the obese group, and obese patients were twice as likely to
have a diagnosis of diabetes mellitus. This nding is espe-
cially salient, as recent studies have shown that obesity not
only contributes to chronic systemic illness but also can pose
problems for orthopedic patients.
Similar to our ndings, other studies have shown longer
surgical times and longer hospital stays in obese patients24,25
as well as more frequent complications for elective orthopedic
patients.2631 Previous studies of various groups of trauma
patients have described an association between obesity and
complications,4,710,32,33 specically sepsis,4,6 other infec-
tions,4,10 organ failure,5,6 and death.68 It is believed that dia-
betes mellitus and potential for poor glycemic control may
contribute to septic complications in diabetic patients.8,26,27,33
Other studies have reported diabetes in association with obe-
sity, similar to our data.8,9,17,26,27,33 Consistent with these stud-
ies, we identied more complications in obese patients.
Signicantly, more infections and renal failure were found.
More DVTs were identied when controlled for age or ASA
score. Corresponding increases in length of hospital stays and
mechanical ventilation times were also detected in our obese
patients. This is similar to other studies on blunt general
trauma patients.4,68
Considering the higher complications and increased
utilization of resource-intensive treatment measures, we
anticipate higher costs of care although our study did not
specically measure costs.34 We also reported signicantly
longer surgical times and longer times on mechanical ven-
tilation in our obese patients, both of which would be asso-
ciated with higher costs of initial care. These ndings are
even more concerning because hospitals are under increas-
ing scrutiny for rising costs. The Center for Medicare and
Medicaid Services, as well as some insurers, has begun to
penalize hospitals and providers for complications and read-
missions, which may occur with higher frequency in obese
patients. Neither the occurrence of trauma nor underlying
patient risk factors such as obesity is under the control of
the providers of care.
Of note, we observed longer surgical times and a trend
toward more frequent loss of fracture xation and secondary
procedures in our obese patients. These ndings are likely
attributable to the difculty obtaining adequate fracture
reduction and xation in obese patients and are consistent
with the previous work demonstrating increased loss of
fracture xation in obese patients with ankle or pelvic
injuries.1214 These factors also translate into greater costs
of care for obese patients.34
Despite no difference in overall injury severity or injury
to other body systems, obese patients experienced longer
delay to the time of denitive xation when compared with
nonobese patients. This was primarily due to surgeon choice
to delay these cases. Of note, the mean duration of surgery
progressively increased with increasing BMI. The mean
duration of surgery in morbidly obese patients was 30%
longer versus nonobese patients. It is possible that surgeons
faced with anticipated longer procedure times and associated
difculty due to technical and imaging considerations in
larger patients deferred these procedures until more favorable
conditions, including time and personnel, were available.
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J Orthop Trauma  Volume 29, Number 11, November 2015
The strengths of this study are numerous. The data were
collected prospectively over a short period of time with strict
oversight of the data, ensuring accuracy. A large proportion
of our study cohort was obese, allowing us to have narrow
condence intervals. Furthermore, the severity of injury in
our patients was consistent with other studies investigating
obesity in general trauma, allowing us to make direct
comparisons to the existing literature. Weaknesses include
a disparity in age and gender in the obese and nonobese
populations. Some of these differences may be unavoidable
due to the direct relationship between body weight and age,
both increasing over time (0.093 BMI points per year; r2 =
0.041, b = 0.093, P , 0.01).20,22 We performed regression to
account for age, and BMI remained an independent predictor
of these outcomes. However, our sample size was not large
enough to detect statistical differences between obese and
nonobese groups for certain comparisons, such as differences
in pulmonary complications, MOF, or mortality, as we would
have required more than 3000 patients.
Optimization of care for obese orthopedic patients is
critical for trauma centers. Obese patients form a substantial
portion of the patient population in the United States, and the
percentage of patients who are obese is likely to increase in
the future. It is clear that care of obese patients raises unique
challenges. Elucidating the risks associated with treating
obese patients is necessary to determine if action can be
taken to optimize treatment not only to avoid costs associated
with increases in ICU days, mechanical ventilation times, and
infections and other complications but also to benet these
often challenging patients.
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