Annotated Source List

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Annotated Source List
Amin, A. K., Patton, J. T., Cook, R. E., & Brenkel, I. J. (2006). Does obesity influence the
clinical outcome at five years following total knee replacement for osteoarthritis? Bone &
Joint Journal, 88, 335-340.
https://doi.org/10.1302/0301-620X.88B3.16488.
Summary:
This journal article states that obesity is linked to the development of osteoarthritis. After total
knee replacements (TKR), obesity will transfer stress through the TKR to surrounding bone,
causing speculation for unfavorable outcome for the replacement surgery. This study focused on
the outcomes five years after TKR in osteoarthritic patients. It was also found that the non obese
patients were typically older than the obese ones. While the obese patients had slightly less
function and knee scores after surgery, they also had lower ones before surgery, so at the five
year mark there is no evidence that proves obesity has adverse effects on total knee replacement.
There have been some similar other studies that support this finding of no effect, while others
say there is a negative effect present. This experiment states that a possible reason for the
relatively equal outcomes could be that obese people are less active than non obese people,
which may compensate and in a way and balance out the loads.
Application to Research:
Since by topic takes a look at the effect of obesity on the recovery of TKR, this source was
incredibly helpful in that it gave me a starting reference for the effects, and will help lead me on
where to search next.
B. Chase, personal communication, December 17, 2017.

Summary:
In an email from Brad Chase some of my questions regarding contraindications in knee implants
were answered. He explained that the implants his company sells list obesity as a
contraindication and that all the surgeons he works with will tell their patients to lose weight
prior to surgery. One of the reasons for the suggested weight loss is because being obese or
overweight has a large impact on the rehab process of the surgery, which affect the function
gained as well as the lifespan of the implant. Lastly, he sent me information on the implants his
company, djo surgical, makes. Included was the list of contraindications, with obesity listed.
This information was useful because it answered questions I was left with after a previous
reading report. It was especially helpful to have a human source to get exactly the information I
was looking for.
Carson-DeWitt, R. (2002). Obesity. The Gale Encyclopedia of Medicine, Vol. 4, 2373-2378.

Retrieved from
http://go.galegroup.com/ps/i.do?p=GVRL&sw=w&u=hcpub_hebron&v=2.1&it=r&id=G
ALE%7CCX3405601117&asid=c3f54b27bffd15fa94512c7a3497771a
Summary:
This encyclopedia entry defines obesity as being 20% or more over the ideal body weight for an
individual: 20-40%- mildly obese, 40-100% moderately obese, and >100% is morbidly obese.
An individual's BMI can measure their obesity. It is found by multiplying your weight by 703
and then dividing by their height squared in inches. There are around 300,000 deaths per year
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attributed to obesity. It is caused when more calories are consumed than the body can burn, and
these calories are stored as fat (adipose) tissue. Exercise can only reduce the size of fat cells, not
destroy them. Obesity can give rise to many secondary conditions: arthritic and orthopedic
issues, high cholesterol, and high blood pressure. Hyperlipidemia is a high level of lipids in
blood plasma. Hyperplastic obesity is excessive weight gain as a child, causing the creation of
new adipose cells. Hypertension is high blood pressure. Hypertrophic obesity is the excessive
weight gain in adulthood causing the expansion of existing adipose cells.
Obesity is the independent variable in my research, so it is important for me to understand as
much as possible about obesity. This was helpful in defining obesity for me, and allowing me to
understanding what causes obesity and what obesity can cause.
Chelly, J. E., Greger, J., Gebhard, R., Coupe, K., Clyburn, T. A., Buckle, R., & Criswell, A.
(2001). Continuous femoral blocks improve recovery and outcome of patients undergoing
total knee arthroplasty. The Journal of Arthroplasty, 16, 436-445.
https://doi.org/10.1054/arth.2001.23622
Summary:
This journal article discussed pain medication for total knee arthroplasty. The frequent
occurrence and severity of postoperative pain in lower extremity arthroplasties implies that pain
control for these surgeries need revision. Continuous femoral infusions (CFI) enhanced rehab as
well as shortening the time at rehab facilities in total knee arthroplasty (TKA) patients. There
were no significant differences caused by age, weight, or preoperative medical history. The use
of perivascular and static blocks reduced hypotension as well as decreasing the need for
isoflurane or fentanyl. CFI patients had less mild pain than fentanyl (EPA) patients, as well as
decreased nausea and constipation. There was no impact on the amount of patients who got
infected. CFI provided better pain control with fewer side effects than did PCA morphine or
EPA. CFI reduced patient rehab time by increasing performance of continuous passive motion
(CPM) and by limiting side effects and complications. Both CFI and EPA decreased blood loss
compared to general anesthesia and morphine. CFI patients could also walk sooner
postoperatively than those who had PCA morphine. CFI patients also had less episodes of fever
than those who received PCA morphine or EPA. EPA is still the best analgesia for TKA, but has
some risk such as epidural hematoma or abscess.
My topic has to do with the recovery of lower extremity total arthroplasties. This was helpful in
understanding what medication is best used to jump start and complete the rehabilitation process.
Craik, J.D., Bircher, M.D., & Rickman, M. (2016). Hip and knee arthroplasty implants
contraindicated in obesity. Annals of the Royal College of Surgeons of England, 98, 295-
299. doi 10.1308/rcsann.2016.0103
Summary:
This journal article describes how obesity may contradict the implant use. It says that obese
patients exerts greater loads on the implanted prostheses. Some manufacturers will list “obesity”
as a contraindication for the use of implants. In nine out of 25 implant components looked at,
obesity or pathological obesity was listed as a contradiction or recommended against the implant,
and all remaining implants advised caution with the risk of obesity. Conflicting conclusions in
literature; some authors say obesity has no negative effect on functional improvement while
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others say obese patients have poorer postoperative function, quality of life, and satisfaction
(probably compared to the non obese). Surgeons are either unaware of these contradictions or are
choosing to ignore them. There is also an inherent flaw in using BMI as the scale for obesity.
This source was unique and looked at the ethical side of using implants in obese patients. It was
useful in that it gave me a lot of knew information to branch off into.
C.F. Mess, personal communication, January 3, 2018.

Summary:
In an interview with Dr. Charles Mess of Potomac Valley Orthopedic Associates, I was
informed on differences between obese and nonobese patients undergoing total knee
arthroplasties. From a surgeons perspective, the surgery is more complicated and takes a longer
time to perform in obese patients. He would prefer having the patient lose weight preoperatively,
and he suggests that his patients do so. He also shared that he knows some hospitals are
implementing BMI or weight limit restrictions when it comes to total knee replacements just
because of the extra costs incurred and the speculation of lesser improvement. He stressed that
although they might have less improvement, an obese patient still has a much higher quality of
life postoperatively and the surgery is not a waste. Finally he adds that obese and nonobese
patients tend to all reach their goals and regain the functions they want to, but this may be
because the obese patients set lower goals or have lower expectations compared to the nonobese
patients.
This was one of my most helpful sources because it answered my own questions, and I did not
have to search through information to find what I was looking for. It also answered some of the
less obvious questions and gave a deeper, more selective look into the topic.
Davidson, T. (2002). Joint Replacement, The Gale Encyclopedia of Medicine, Vol. 3 (2nd ed)
Retrieved from
ALE%7CCX3405600886&asid=4428a35888bca5805d82def90a6cf77a
Summary:
This encyclopedia entry describes total joint replacements. Over two thirds of joint replacement
surgeries are because arthritis has limited motion and caused pain to the joint. The most common
total joint replacement surgeries are knees and hips. For both these surgeries, a metal and plastic
prosthesis is mounted where the bone was taken from. The prosthesis is either held in place with
cement or with natural bone in-growth, the latter of the two is sturdier. After surgery, pain
medicines are usually necessary and physical therapy begins, first passive followed by active.
Nerve injury and infection are the main risks of these surgeries; however, ninety percent off joint
replacements are successful. After a certain period of time, the prosthesis can loosen and more
surgery may be required; the typical period is fifteen years.
I am narrowing down my topic to joint replacements, so this gave a good foundation for that.
Also my mentor does a lot of hip and knee replacements so this entry was a great place to start
and will allow me to narrow down my search further.
DrSyedJunaid. (2012, February 6). Classifying and presenting Fractures - Orthopaedics for
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Medical Students / Finals. Retrieved from

https://www.youtube.com/watch?v=UraJfkuSuUI
Summary:
This video explains how to describe and view fractures on X-Rays. First an X-Ray should be
described by the side of body (left or right), part of body, view (AP or Lateral), and surrounding
joints. There are nine types of fractures: transverse (less than thirty degrees), oblique (greater
than thirty degrees), segmental (two pieces), comminuted (more than two pieces), spiral,
avulsion (tendon pulls bone off), impacted (forced coming together), toras, and greenstick. Next
the X-Ray should be read for displacement (the two sides of the fracture do not line up);
displacement should be described by what side and how much (%). Fractures could also be
angulated (fractured through only part of bone, still in one piece, like a hinge); direction and
angle should be stated. Shortening is when there is a displacement that overlaps and shortens the
length of the bone. A fragment of the bone can also be rotated.
This was incredibly useful because know I will understand when Dr. Mess describes fractures he
sees in X-Rays. I have heard vocabulary in this video that I have heard doctors use that I
previously didn’t understand but I now do. The most helpful reading report I have done.
Foran, J.R., Mont, M.A., Etienne, G., Jones, L.C., & Hungerford, D.S. (2004). The outcome of
total knee arthroplasty in obese patients. The Journal of Bone and Joint Surgery, 86,
1609-1615.
Summary:
This journal article was done to compare total knee arthroplasties between obese and nonobese
patients. At five year, obese patients had lower function scores, and at 10 years, both groups had
similar prosthesis survival. In this study 88% of obese patients had a successful surgery, and
99% of nonobese patients had a successful surgery. Between 60 and 80 months is when
decreased survival rate in the obese patients became apparent. Obesity has a negative effect on
the recovery of total knee replacements. At a mean of seven years postoperatively the obese
groups had significantly lower rates of success than nonobese. They obese patients also had
lower postoperative knee scores and lower satisfaction levels. Morbidly obese patients have the
same effects of obese patients but to a greater magnitude.
This source was useful to my research because it explains what differences arose between the
obese groups and nonobese groups during the recovery of total knee arthroplasty, and it also
addresses morbidly obese patients.
Frey, R. (2015). Knee Replacement. The Gale Encyclopedia of Medicine, Vol. 5, 2878-2886.
Retrieved from
ALE%7CCX3623301054&asid=114d7c0fca7bfd0da2234edcd7e27bf9
Summary:
This encyclopedia entry explains total knee replacements (TKR). The operation is called
arthroplasty, which is the reforming of a joint. The purpose of TKR is for pain relief, usually in
arthritic patients. The knee is the body's largest and most vulnerable joint. 70% of TKR are
performed on patients over 65 years of age. TKR is harder than hip replacements because the hip
does not depend on ligaments for stability. The metal and plastic prosthesis is cemented or
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inserted into place. Before surgery, a patient must be diagnosed. Diagnosis takes the form of a
physical and visual examination as well as some sort of imaging. Patients are typically in the
hospital for five to ten days after the surgery, and during this time they begin physical therapy.
The surgery should provide pain relief and a greater range of motion. Prosthesis are expected to
last 10-15 years, and there is not yet an expectancy for non cemented in prosthesis because it is
such a new technique.
This source was useful in that it gave me a better understanding of total knee replacements.
Understanding the difference between total knee and total hips is crucial for my research, and the
article helped with that.
Frey, R., & Carson-DeWitt, R. (2015). Hip Replacement. The Gale Encyclopedia of Medicine,
Vol. 4, 2439-2446. Retrieved from
ALE%7CCX3623300892&asid=06d62352c2d677898ca16cbf29af330e
Summary:
This encyclopedia entry explains total hip replacements (THR). This is another type of
arthroplasty. THR is only considered once the pain becomes unbearable, and if it is undealt with
can lead to suicide. The other purpose of THR is to regain joint function. Most THR patients are
over 60 years old. There are three types of THR: standard, minimally invasive, and revision.
Surgery takes anywhere from an hour and a half to three hours. A hole is drilled in the femur and
the prosthesis goes into the hole and is either held in place or cemented in. Hip prosthesis
generally last longer than knee ones. The diagnosis for this issue looks deeply into family
history. After surgery, the patient stays in the hospital for typically five to ten days. The therapy
starts here and and continues for four to five months after.
This article was a supplement to the one above in that it helped me to understand the similarities
and differences between the THR and TKR. There was not as much detail about the recovery of
the surgery as I was looking for.
Hench, P. S., Kendall, E. C., Slocumb, C. H., & Polley, H. F. (1949). The effect of a hormone
of the adrenal cortex (17-Hydroxy-11-Dehydrocorticosterone: compound E) and of
pituitary adrenocorticotropic hormone one rheumatoid arthritis. Annals of the Rheumatic
Diseases, 8 (2), 97-104. http://dx.doi.org/10.1136/ard.8.2.97
Summary:
This journal article describes the effects of 17-Hydroxy-11-Dehydrocorticosterone, better
known as compound E, on Rheumatoid arthritis patients. The goal of the researchers was to find
a drug that mimicked the effect of pregnancy and jaundice on rheumatoid arthritis. Compound E
was injected into a patient initially and after 48 hours started taking effect. It was then opened up
to multiple trials. The results are discussed and data is displayed. Results talk about initial effects
of compound E, dosages, effects of long term versus short term administration, laboratory effects
(including corticosteroids), and side effects. Also, the acetate of compound E was discovered
which has similar effects and cost less, so some patients in the experiment were administered
compound E acetate. The journal also touches on adrenocorticotropic hormone (ACTH) but in
less detail because it was only tested on two patients; it had overall the same effects.
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This source is dated but is important in understanding the basics of hormone treatments for
arthritis. This explains what the goal of researchers were and how they accomplished it, which is
important since my topic is arthritis treatments, and since I witness injections often at my site.
Hoyle, B. (2014). Arthritis. The Gale Encyclopedia of Science, 5th ed., Vol. 1, pp. 328-329.
Retrieved from
http://go.galegroup.com/ps/i.do?p=GVRL&sw=w&u=hcpub_hebron&v=2.1&id=GALE
%7CCX3727800197&it=r&asid=f1313beb5ac868c998089c06578eedd8
Summary:
This online encyclopedia gave a basic description of arthritis. 50 million Americans suffer from
arthritis, and there are over 100 different types. The two most common types are Osteoarthritis,
the gradual wearing away of the cartilage (allows bones to move smoothly), and Rheumatoid
arthritis (RA), which occurs when the synovium (a network that eases frictions of bone rubbing
by using fluid) surrounding a joint becomes inflamed, and the body’s immune system begins to
attack the joint. Osteoarthritis is caused by overuse or injury, so it is more common in adults.
Rheumatoid arthritis is common in both adults and children. The cause of rheumatoid arthritis is
still unknown, but almost half of all cases are genetic. Treatment for osteoarthritis is usually
nonsteroidal anti inflammatory agents (NSAIDs), such as aspirin or other pain killers. Some are
sold over the counter but high doses require a prescription. NSAIDs usually work in the same
way to suppress prostaglandin, but some people experience different adverse effects. A treatment
for rheumatoid arthritis and osteoarthritis are corticosteroids, such as cortisone, which slow the
disease down and hopefully have it go into remission by suppressing immune response.
Treatment can last anywhere from days to years, and because the treatment suppresses immune
responses, it must be monitored by a physician.
So far at my internship I would say half of all cases I have seen are arthritis, so I am considering
doing my project on that because I would have the easiest time collecting data. This article was
helpful for me as it allowed me to better understand arthritis, such as knowing there are multiple
types. Now while looking at X-Rays I will be able to tell what I am seeing, and I will also be
able to differentiate the type of arthritis based on listening to the “causes” I hear.
Khanacademymedicine. (2015, May 15). “Osteoarthritis vs rheumatoid arthritis symptoms |

NCLEX-RN | Khan Academy.” Retrieved from
https://www.youtube.com/watch?v=H-OoyU8Gb_Q
Summary:
This video explains the similarities and differences in the causes and symptoms of rheumatoid
arthritis (RA) and osteoarthritis (OA). RA is caused by an autoimmune disorder, while
osteoarthritis is due to overuse and is especially present in old and overweight people. Symptoms
of both types of arthritis are pain, stiffness, weakness, and even some psychological effects, such
as depression. In RA, patients experience the arthritis symmetrically or in the same joints
contralaterally, and OA is asymmetrical. RA affects the proximal interphalangeal joints while
OA affects the distal interphalangeal joints. In RA, symptoms are worse in the morning and get
less severe throughout the day, while OA is worse after activity and not as bad in the morning.
Affected areas of RA become red and feel warm, and in OA they become swollen. OA patients
bone’s make crepitus, the sound of bone grinding on bone. OA also slowly worsens over time,
while RA is random or cyclical. Along with the RA cycles comes fever and malaise.
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I am doing my research on arthritis so this video was helpful in that it cleared up my confusion
on the differences between the two main types of arthritis. Also when hearing new patients at my
internship I will be able to come up with my own more specific diagnosis of arthritis.
Larson, J. (2012). Orthopedics. Applied Science, 1337-1382. Retrieved from

http://search.ebscohost.com/login.aspx?direct=true&db=sch&AN=109460672&site=scirc
-live
Summary:
This journal article describes orthopedics as a field. Orthopedics studies the musculoskeletal
system: bones, muscles, and joints. Orthopedic injuries can be treated with medication,
injections, therapy, or surgery. Orthopedic surgeons investigate patient problems and order tests
such as X-Rays or MRIs to determine an issue, and once the issue is determined a plan for care is
drawn up. This source shares plans for treatment of fractures, joint pain and dysfunction,
developmental disorders, sports injuries, and emergency situations. One common solution is
arthroplasty, or joint replacement with a metal or plastic prosthesis; however, these experience
wear and eventually fail. Another common procedure is arthroscopy, which allows a surgeon to
examine a joint, and also repair and remove debris, all while not exposing the joint. Since most
military injuries are to the musculoskeletal system, the United States Department of Defense
fund orthopedic research, as well as many universities. The steps on becoming an orthopedic
surgeon are first obtaining a bachelor degree, and then going to medical school, followed by five
years of residency: the first year being general surgery residency and the next four being training
in orthopedic surgery. Sports medicine is a growing field in orthopedics.
I found this source to be helpful because it laid out for me the field of orthopedics, which I have
not formally done before. Many topics that occur during my internship were present in this
article, so it will be useful when it comes time to data collection for narrowing down the area of
orthopedics I study.
LifeBridge Health. (2016, January 17). What to Expect After Hip Replacement Surgery.
Retrieved from. https://www.youtube.com/watch?v=SS2Z2AXX8kA
Summary:
This video explains the recovery process of total hip replacements. After surgery, doctors and
attending determine how long the patient must stay in the hospital, and whether they will be
discharged to home or to a rehab facility. If the patient goes home, physical therapy comes to the
home for a couple of weeks. Pain management goes for three months after the surgery. Physical
and occupational therapy are important and start within the first 24 hours. Certain motions
cannot be done for six weeks after surgery, such as bending over, so tools are given to patients.
Patients are given home exercise programs and must do them daily for the first six weeks.
Patients also need to use durable medical equipment (DME), such as walkers, crutches, and
canes. Subcutaneous closure is used, so the site should not be wet for the first two weeks. Pain
medication should be taken prior to physical therapy.
This source was useful to my research because it expanded upon the recovery period of total hip
replacements, which is similar to that of total knee replacements. I will be able to compare
information from this source to information on total knee replacement recoveries.
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L. Esposito, personal communication, December 20, 2017.

Summary:
In her email, she answered some questions of mine regarding her article on obesity and total
knee replacements. Her article described a woman with bilateral knee replacements and her
struggles with finding a surgeon to operate on her. The woman had a fine recovery and was
doing well, and in her email, the author explained that she believed the woman she wrote about
was not an exceptional case and that obese patients do not experience a “worse” recovery than
non obese patients. She also said that surgeons are less likely to perform a total knee replacement
on an obese patient if they do not have prior experience doing so. She also added an important
point at the end of her email, saying that as obesity is rising, there is going to be an increase in
demand for total knee replacements by obese patients, so surgeons are going to have to start
getting comfortable performing this operation on them.
In all my research, this was one of the first non-journal article to come up, so I thought it would
be interesting to reach out to the author. She turned out to be very helpful and added some
insight into my research that I might not have received from a researcher or surgeon.
Mizner, R. L., Snyder-Mackler, L., & Stevens, J. E. (2003). Quadricep strength and volitional
activation before and after total knee arthroplasty for osteoarthritis. Journal of
Orthopedic Research, 21, 775-779. http://onlinelibrary.wiley.com/doi/10.1016/S0736-
0266(03)00052-4/epdf
Summary:
This journal article discusses problems with quadriceps after total knee replacement surgeries.
One consequence of the surgery is often quadricep femoris weakness. The researchers assigned
certain physical therapy to postoperative patients and used the Activities of Daily Living Scale of
Knee Outcome Surgery (KOS) to describe the effect of pain on the patient's activity. Quadricep
strength was assessed 10 days before surgery and 26 days after. Maximum voluntary force was
compared before and after surgery. The KOS showed improved scores after surgery. The
involved quadriceps were weaker than the uninvolved ones, and after the surgery the quadriceps
strength of the affected leg decreased 60%. Half of the muscle loss can be attributed to
arthrogenous muscle inhibition (AMI). Muscle atrophy was not the predominant cause of the
AIM after surgery. In order to restore the full function of quadriceps postoperatively patients
must be involved in more vigorous therapy and should be done in the first month after surgery.
This source was useful because it discussed one of the factors that impedes the recovery of total
knee replacements. This could relate to my topic as being a factor that affects recovery.
Reilly, D.T. (2017). Harvard expert: What you can expect from knee and hip surgery. Retrieved
from
https://www.health.harvard.edu/healthbeat/harvard-expert-what-you-can-expect-from-
knee-and-hip-surgery
Summary:
This website article is an interview with a total hip and knee replacement surgeon. He explains
that from a surgeon's point of view, total hip replacements (THR) are easier that total knee
replacements (TKR) because the knee is just harder to get to and operate on. From a patient's
Drohat 9
perspective, THR recover quicker and the end product of recovery is a more normal feeling,
whereas a TKR takes sixth months to a year to completely recover and patients report even then
it does not feel normal. This is because the hip is a simpler joint than the knee. To perform
surgery on the knee, more soft tissue and bone must be removed so there is a greater area
affected. He says the best ways to stay clear of total joint replacements are to stay active, keep
muscles strong, and not get obese.
I am probably going to do my research on the differences between the recoveries of THR and
TKR. This source was helpful in that it gave the surgeon's perspective on the two as well as the
patients, and then gave a basis as to why patients may have felt this way.
Rodriguez-Merchan, E.C. (2014). The influence of obesity on the outcome of TKR: can the
impact of obesity be justified from the viewpoint of the overall health care system. The
Musculoskeletal Journal of Hospital for Special Surgery, 10, 167-170. DOI:
10.1007/s11420-014-9385-9
Summary:
This journal article discussed the impact of obesity on outcome of TKR. There is controversy
over performing TKR in obese patients because of their increased risk for poorer outcomes. This
was a meta analysis of many papers about the effect of obesity on TKR outcome. There was
found to be no difference in the functional outcomes; however, in obese patients, risks of
complications were higher and the rate of prosthesis survival was lower. While a BMI of 30 is
not associate with worse outcomes, a BMI > 40 is. Obese patients without diabetes had better
outcomes than those with diabetes. After 5 years morbidly obese (BMI > 40) patients had a
lower implant survivorship than obese and non obese patients. While obese patients seem to have
a net gain from surgery, morbidly obese patients should postpone surgery until they are able to
get their BMI down. Morbidly obese people also have a 7% higher hospital bill.
This source was helpful in that it analyzed 50 studies in order to draw conclusions about the
effects of obesity on TKR. The study also went into detail of three distinct categories: non obese,
obese, and morbidly obese, which I thought was a good format.
Salih, S. & Sutton, P. (2013). Obesity, knee osteoarthritis and knee arthroplasty: a review. BMC
Sports Science, Medicine and Rehabilitation, 5. doi:10.1186/2052-1847-5-25
Summary:
This journal article describes the relationship between implant survivorship and obesity. Knee
osteoarthritis is becoming more common because obesity is becoming more common. Obese
people have a three fold risk in developing OA. The theory is that there is an increased
prevalence of OA in obese people because the extra force they exert on their joint. Knee pain is
subjective in obese patients, and might be caused by secondary factors of obesity and not so
much by OA- unsure. The surgery takes longer in obese patients, it is harder to identify the
anatomy, and has a higher risk for malalignment. After five years there is no increased revision
rate in obese patients, but after seven years the implant failure rate was higher in obese patients.
There are reportings that obese patients are less happy with their postoperative results, but it may
again be caused by obesity secondary issues. After 80 months there was better survival rates in
morbidly obese than obese, but both were worse than non obese.
Drohat 10
This source was helpful because it analyzed the lifespans of the implants in obese, non obese,
and morbidly obese patients. It was useful because of all the different time periods analyzed at.
Stevens-Lapsley, J.E., Peterson, S.C., Mizner, R.L., & Snyder-Mackler, L. (2009). The impact of
body mass index on functional performance after total knee arthroplasty. The Journal of
Arthroplasty, 7, 1104-1109. doi:10.1016/j.arth.2009.08.009.
Summary:
This journal article describes the effects of obesity on the recovery of TKAs. Obesity can cause
osteoarthritis. “For every pound of weight loss in patients with OA, there is a 4-fold reduction in
the load exerted on the knee with daily activities.” This study used the “timed up and go” (TUG)
test and self reporting questionnaires as part of their data collection. One questionnaire used was
the Activities of Daily Living Scale of the Knee Outcome Survey (KOS-ADLS). There was no
significant functional difference between obese and non obese patients, but there may be a
difference when BMI surpasses 40𝑘𝑘/𝑘2 . Obese patients pose a greater risk for performing the
operation. A BMI < 40𝑘𝑘/𝑘2 has minimal effect on outcome. Obese patients have lower
functional scores but showed the same net improvement as did non obese patients. It is difficult
for the OA patients to lose weight preoperatively because of the problems posed by the OA.
Obesity is becoming more prevalent so the impact of it on TKA should be examined.
This source was helpful in that it assessed the effects of obesity on TKA. They mentioned ways
of measuring function that I could use to create my own methods for data collection. This stated
at around what level of BMI that obesity might start to take effect on TKA.
Talking With Docs. (2016, June 17). Everything About Total Hip Replacement Surgery—
Talking with Docs. Retrieved from. https://www.youtube.com/watch?v=xVAq2eyGXa0
Summary:
This video contains specific information, visuals, and tools of total hip replacements. Total hip
replacements have a femoral component with a ball on the end and a socket that is inserted into
the acetabulum (pelvis). They can be metal on polyethylene or ceramic on ceramic. There are
multiple approaches to THR; surgeons will try to be minimally invasive, but will make the
incision as large as necessary. Spinal anesthetics are first choice for THR. After surgery, the total
hip could dislocate or also a leg length discrepancy could occur. Patients are usually in the
hospital for two to three days after, and should be walking the day after surgery. The goal of
postoperative patients should try to avoid dislocations (turning out too far or bending too much)
or periprosthetic fractures. No repetitive, high-impact activities. Hips will last around 15 years,
but it is unsure because new materials are constantly being used. Another mode of failure is
infection; bacteria will stick to the foreign object in body and must be surgically treated. Hip
replacement patients are usually more satisfied than knee replacement patients.
This source was helpful in that it explained many frequently asked questions about total hip
replacement from the perspective of surgeons. Their input is useful as it elaborates on the details
on THR and gave me a more deeper and practical look rather than just a clinical definition.
Uretsky, S. D., & Wells, K. R. (2015). Corticosteroids, systemic. The Gale Encyclopedia of
Drohat 11
Medicine, Vol. 2, 1356-1360. Retrieved from

ALE%7CCX3623300488&asid=14c44db74f93be5f534063b28572343a
Summary:
This online encyclopedia provides an overview of corticosteroids, which are a group of drugs
that are chemically related to hormones created by the adrenal gland. The two primary adrenal
corticosteroids are cortisol (glucocorticoid) and aldosterone (mineralocorticoid). Glucocorticoids
inhibit immune responses, which allows them to be used as treatment for many diseases, but it is
not a cure. Cortisone and hydrocortisone both have glucocorticoid and mineralocorticoid effects
and are preferred in treating adrenal insufficiency. Cortisone is less potent than hydrocortisone,
but hydrocortisone has a longer duration of effect, even though they are both considered short
acting. Prednisone is immediate acting and dexamethasone is long acting. Recommended dosage
of cortisone is 25 mg and of hydrocortisone is 20 mg. When administering these drugs, the
adrenal gland produces less of it; if someone is coming off the drug they must ease of of it with
decreasing dosages. Since immune response is suppressed, there are many precautions when
taking corticosteroids. They also cause adverse side effects, and may interact with other drugs,
such as ones that stimulate liver enzymes or aspirin, and decrease their function.
At my internship many patients with arthritis request cortisone injections, so I have experienced
a few of those. This source was useful in explaining what these injections are and how they
work, and allows me to better understand what I am seeing.
Vaishya, R., Vijay, V., Wamae, D., & Agarwal, A.K. (2016). Is total knee replacement justified
in morbidly obese? A systematic review. Cureus Journal of Medical Science, 8. Doi:
10.7759/cureus.804
Summary:
This journal article explains that surgeons are skeptical when it comes to TKAs because of the
outcomes and complications, stemming from diabetes, hypertension, coronary artery disease,
cancer, and of course OA. The overall complication rate was higher in ⅞ of the studies looked at.
Functionality scores did not vary remarkably in the short term between the non morbidly obese
and the obese groups because of equivalent mean improvement. One study found that survival
rates at 14 years for non obese and obese were 49% and 71% respectively. This is probably due
to the active lifestyle of the non obese patients. The morbidly obese had lower satisfaction and
functionality compared to the non morbidly obese. Morbidly obese patients also had significantly
more superficial infections, but there was no significant difference in deep infections. Some
studies suggested that it is not BMI which has an effect but rather just absolute body weight.
Morbidly obese patients should be screened before surgery to ensure it is worthwhile.
There was a lot of great introduction material. This was helpful because it as a meta analysis
assessing many different sources to give me an overview. Good imagery and graphs.
Wang, C., Guo, Y., Shi, J., & Chen, W. (2017). A numerical investigation into the effects of
overweight and obesity on total knee arthroplasty. Journal of Healthcare Engineering,
2017. doi:10.1155/2017/1496379
Summary:
Drohat 12
This journal article gives a plethora of reasons to believe that obesity will have a negative
impact on the recovery of total knee arthroplasties both in terms of their duration and
functionality. Increased weight led to higher forces at the interface between bone and the TKA,
increasing the risk for loosening. A cementless TKA might be better for morbidly obese patients
in order to increase duration (better tolerate heavier load). Increased contact pressure causes
more wear to the implant. Obese patients also have a shorter step, requiring more steps to cover
the same distance and putting more (unnecessary) wear on the implant. The best TKA for an
obese patient is cementless with a thick polyethylene tibial insert and a thin metal tibial tray.
This sources was useful because it explained many reasons why doctors and researches suppose
obesity will have a negative effect on recovery. They also offer possible solutions to some of the
problems, which was unique.

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B. Chase, personal communication, December 17, 2017.

Carson-DeWitt, R. (2002). Obesity. The Gale Encyclopedia of Medicine, Vol. 4, 2373-2378.

C.F. Mess, personal communication, January 3, 2018.

Medical Students / Finals. Retrieved from

Khanacademymedicine. (2015, May 15). “Osteoarthritis vs rheumatoid arthritis symptoms |

Larson, J. (2012). Orthopedics. Applied Science, 1337-1382. Retrieved from

L. Esposito, personal communication, December 20, 2017.

Medicine, Vol. 2, 1356-1360. Retrieved from

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