Jumping Through Hoops for Knee Surgery

knee surgeryOne of the most read and shared blog posts I’ve ever written is about fat people and our knees.  Today we’re going to look a a specific situation. An incredibly common question that I get is from someone who needs knee surgery but whose orthopedist has refused to perform the surgery unless and until the person loses weight.  This happens with other surgeries as well, but the one I hear about the most is knee surgery.

Sometimes the doctor suggests weight loss through diet and exercise.  I would point out that even if diet and exercise might lead to short term weight loss (and even if they could manage exercise on a knee that required replacement!) the most likely outcome, based on the research, is that they would end up heavier than they started within a few years, which begs the question: If you think that my size is the problem, then why are you are giving me what is  statistically the worst possible advice?

Now I’m hearing more and more from people whose doctor has claimed that knee surgery is “too dangerous” at their weight and has recommended … wait for it … weight loss surgery.  You aren’t reading that wrong – doctors are refusing to fix someone’s knee until they are willing to have their stomach almost entirely amputated.

The first issue here is that the weight loss requirement is generally an arbitrary percentage or number of pounds, creating a situation where even if the patient achieves the prescribed amount of weight loss (short term at least) they are then offered surgery at a size at which the surgeon would have denied them if it was their starting weight. If that’s not completely ridiculous I don’t know what is.

But far worse, suggesting surgery is an extraordinary breach of the idea of “do no harm” since they are asking fat patients to risk their lives and quality of life by having a surgery that is a complete crapshoot in terms of outcome (some people are happy, some people die, some people have horrific lifelong side effects and people don’t know which group they’ll be in until they are in it) so that the patient can get a simple surgery, and the doctor can perform an easier surgery despite the fact that two surgeries are riskier than one. Jumping through hoops to receive knee surgery is bad enough, risking your life to receive it should be out of the question.

But doctors use the realities of surgery on larger bodies as reasons not to give us healthcare, rather than working to solve these issues (for example, if a fat person’s leg is too heavy for one person to hold during the duration of surgery the correct answer is to find another way to hold the leg – an extra person, a device etc. – not for fat people to simply live with chronic knee pain and limited mobility while medical science aggressively shrugs its shoulders.)

Even if you believe that fat people face additional risk from the surgery and/or have less benefit, that doesn’t mean that the procedure should be denied. Less pain and more mobility is a reasonable motivation for seeking healthcare even for patients who are unlikely to have the absolutely best outcome for any of many reasons (which is why Shaquille O’Neal received knee surgery even though it was his plan to continue the professional athlete lifestyle that trashed his knee in the first place.)

None of this is to suggest that if you are refused knee surgery you are under any obligation, or even recommendation, to try to change your doctor’s mind.  That’s certainly an option (and for those who live in areas with limited practitioners and the inability to travel to see another doctor it may be the only option.)  Many people have found that their best option was simply to find a more compassionate and talented surgeon who isn’t interested in simply cherry picking only the easiest surgeries.

Remember that you get to choose the path you take. While you shouldn’t have to do it, you might decide that it’s worth it to try to crash diet to lose that 20 pounds the doctor asked for so that you can get your surgery – knowing, of course,  that you’ll be gaining the weight back again and probably more. Maybe it’s worth it (and you have the resources) to travel to see a surgeon who doesn’t practice from a base of fatphobia.  Maybe you want to turn this into activism and start insisting that the doctor provide proof that you can lose weight long term (they can’t) or that you won’t die or have horrific longterm side effects from the surgery (they can’t) and then lobby for the procedure since their position is baseless.  Or be super extra nice and try to sweet talk them into it. Sometimes trying to access medical care in a deeply fatphobic society means doing whatever it takes to get the care we deserve.

If you’re looking for a fat friendly doctor you can check out the international fat friendly doctor list at http://fatfriendlydocs.com (If you have a fat friendly doctor, please take a moment to add them to the list!.)

If you want to help make the world – including medical care – less fatphobic, join us (online!) for the Fat Activism Conference:

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22 thoughts on “Jumping Through Hoops for Knee Surgery

  1. Thanks so much for this very timely post Regan. I am actually scheduled for my 1st of 2 knee replacements beginning of August. Hospital of Special Surgery in NYC has been very fat positive actually. I met with 3 Dr’ s for consultations from this hospital, all of whom took a strong stand against the many practitioners that insist on weight loss or weight loss surgery prior to knee replacement. The only caveat is that they wouldn’t perform both at the same time because my “BMI”was too high…”hospital policy”. I had to really “prepare” myself as I ventured into the medical establishment, as so many of us do…It can be a very vulnerable and emotional experience to advocate for ourselves. I had some really negative, fat shaming experiences in the last year, prior to getting to this particular hospital.
    Well…I’m pretty anxious about the upcoming surgery…the rehab particularly but I’m ready! Wish me luck and thanks so much for all your wonderful blog posts!!

  2. I need knee surgery, and was told by the orthopedic surgeon, “No insurance company will cover the cost unless you get your BMI down to under 26.5. They just don’t think that it’s worth their time/money to pay to fix a knee that will most likely be destroyed again by the extra weight being carried on it. If you want to pay for it out of pocket that’s fine. Otherwise you need to loose weight (oh btw, knee surgery costs anywhere from $17,000 to $61,000, which I TOTALLY have just laying around). But here’s the really fucked up part. My knee needs to be replaced because I fell in a 2′ hole in my yard that the spoiled brat neighbor kids dug and then neatly cover up with grass hoping I would fall in it because they were pissed that we told them to please play in their own yard (they were breaking the limbs of our fruit trees to get the pears and apples). Well, success on their part because I did fall in it, cracked my meniscus and hit my face on the front of the lawn mower. Yes, I called the police, but they were never able to do anything about it, because the parents refused to ever come to the door and then moved a couple weeks later in the middle of the night. So I’m fucked now with a knee that will never be the same.

    1. OH, that is awful! I hope those kids will come to a lively sense of their own guilt before they reach adulthood.

      Also, I’m sure there are *reasons* why they moved in the middle of the night.

      I am faced with a similar situation. I am going to have an X-ray tomorrow to diagnose my hip. But I know that regardless of what we find out, it’s going to end up as “Well, your insurance won’t pay to fix that problem, so sucks to be you, just take your pain pills.”

      Why do I know that will happen? Because my insurance is better than nothing, but barely. The list of things it won’t cover (including pain management and MRIs!) is longer than the list of things it WILL.

      But, at least I’ll know why I get the sharp shooting pains every time I move my leg, right? Joy.

      My sister, who is also fat, has a bum knee. It has nothing to do with her weight, and everything to do with an auto-accident. But try telling that to jerks who judge her for her weight. They think a diet will miraculously cure broken bones and torn tendons.

      1. Sorry for your hip problem!! I know that can be very painful. I recently had a systemic case of Candida which has caused excruciating pain in my joints, especially my right hip (so bad sometimes I don’t think I’m going to be able to get out of the car). I wound up doing a F-ton of research and reading, and found a supplement that has helped me greatly. Maybe you’ve heard of it, I just want to be sure to share anything that could possibly improve other’s lives. It’s called Noni Fruit. You can get it at a Super Supplements or such. Most people use it in the juice form but I can’t do it, it tastes like you just threw last years christmas tree in the juicer and I could barely gag it down. Fortunately, it comes in a caplet form. It took about a week and now the pain is easing way off! Please, do your research and make sure it’s right for you, but it seems like it was pretty low on possible interactions. Truthfully, with any health concern that might have anything to do with weight, I’ve had much more compassionate and effective help from the naturopathics than the allopathics. Naturopaths tend to look at you as a whole person with many, many dependent and intertwined systems. I hope you can find some relief!

  3. Ragen- I was told exactly that= you’re leg is too heavy for surgery and we don’t have the resources to bring in extra staff” when I needed knee surgery. I was lucky that i life in riverside at the time because to find a doctor in Orange County that was willing to work with my state insurance at the time. It was almost a 3 hour drive in traffic but i was lucky. I can’t imagine living in a more rural place.

    Now that I live in assisted living I see it all day. Every day how fat people are discriminated against. We have “special” beds that aren’t nearly as comfortable, we are more likely to have a room mate because our rooms are bigger and this can be very trauma to someone like me who only lived with my wife and daughter for the past 45 years. We are last in line for medications because and Ive been told “your medications take longer for the pharmacy to prepare” oh yes all fat people? I’ve sunk into a deep depression since moving in here in February march and have gained another 20 pounds lbs. So now I guess my level of treatment is inverted and proportional with the amount of weight and gain and it’s going to get worse?

    1. Wait. What does your weight have to do with how quickly a pharmacy can fill your prescription? That makes absolutely no sense.

      Now, if they had said, “That particular medication takes longer to fill,” it would make sense. I’m sure there are some medications that are just plain fiddly. But that would be the same situation for anyone on that medication, regardless of their size.

  4. TWENTY-SIX POINT FIVE? Okay, that is just ridiculous, even for folks who DO think BMI should have anything to do with surgery. A 5’4″ woman has a BMI of 26.6 at a whopping 155 pounds. That is flat out not very big. (The 50th percentile weight for women in the US is 159.1, and the median height 63.7 inches, just under 5’4″.) Plenty of people much heavier than that have perfectly healthy knees. Assuming the figures are similar for men, they’re basically saying half the people in the US can’t have knee surgery.

    1. I honestly feel like it was just a bullshit arbitrary number of “thin” he threw out. I will NEVER weigh that little. Never. I actually am 5’4″ and have a huge bone structure (thank you stocky ancestors) and even in highschool when I was lean and mean I still weighed closer to 200. Honestly, they can get bent. I’m done with allopathics. Naturopaths have so much more compassion and look at me as a whole person, but just a single problem they can through drugs at.

  5. It seems like it doesn’t matter how much you lose anyway – there are doctors who will continue to demand more. I work with someone who was told to lose 40lbs in order to have a hernia repair. They lost that amount, then were told, “Good job, you need to lose 20lbs more before we can operate.” I still can’t wrap my head around it.

    1. My first thought was, “That doctor just doesn’t want to do surgery, at all, and is too cowardly to admit his laziness to patients, so he blames them for not being good enough, instead.”

  6. Yeah, the logical disconnect between saying, “YOu’re too fat to operate on, so have this operation!” is staggering.

    Also, why would they have someone hold the leg for a surgery? They could get shaky. Why would they not have the leg in some sort of a harness, regardless of weight or size? It should be IMMOBILIZED.

    I love this quote: “while medical science aggressively shrugs its shoulders”, which made me think of Janet Jackson’s “What Have You Done For Me Lately” video, in which she shrugs her shoulders so much that my own shoulders ached in sympathy.

  7. http://www.drsharma.ca/bmi-does-not-affect-outcomes-in-knee-replacement-surgery might be relevant.

    “The researchers prospectively examined the impact of BMI on failure rate and clinical outcomes of 2,438 unicompartmental knee replacements in 378 patients with a BMI less than 25, 856 patients with a BMI 25 to 30, 712 patients with a BMI 30 to 35, 286 patients with a BMI 35 to 40, 126 patients with a BMI 40 to 45 and 80 patients with BMI greater than 45.

    “At a mean follow-up of 5 years (range 1–12 years) there was no significant difference in the Objective American Knee Society Score between BMI groups.

    “Although there was a slight trend to decreasing post-operative function scores with increasing BMI, patients with higher BMI had lower scores prior to surgery. Thus, overall higher BMIs were associated with a greater change in functional scores.”

  8. I am so horrified people have to deal with this crap. Out of curiosity, does the same bullshit go on in places like Canada and the UK or other single-payer places?

    1. I think it does, I knew someone in the UK and her wife needed knee surgery and they were about to go on a diet together (out of support) because the doctor was forcing her to lose weight to get the surgery she needed. I think something changed and she ended up not having to lose, or not as much as she was told she had to lose, or maybe she found a way around the weight loss requirement.

  9. They also don’t even consider the fact that DUH if people have crippling and agonizing arthritis in their knee, they might be overweight because they can’t burn calories by exercising or doing hardcore cardio. I had foot surgery last summer and gained weight BECAUSE I LITERALLY COULDN’T WALK, so no matter how much I restricted my intake, I still was burning nearly nothing. This year I had shoulder surgery for a torn rotator cuff, an injury and chronic problem that would exist in the same amount whether I weighed 120 pounds or 620 pounds, and the orthopedic surgeon told me politely during the pre-op that “any weight you can get off now will help me immensely during the surgery.” (How is that precisely??? My shoulder joint will slim down in the process?) Because, again, I can do a ton of exercising when my right arm is in a sling and I’m living on a ton of pain medicine.

  10. The assumption is that bariatric surgery will improve outcomes, but this 2016 meta-analysis found that WLS before joint replacement did NOT actually improve outcomes. Why do it?

    A number of recent studies have found that nutritional status (malnutrition measured by albumin levels) is a stronger predictor of poor outcome after joint replacement than BMI. If you are forcing people to lose weight to be able to access joint replacement surgery, you are putting them at risk for a poorer outcome if the weight loss is achieved at the expense of nutritional status. https://www.ncbi.nlm.nih.gov/pubmed/28167877

    The good news is that more and more surgeons are loosening BMI restrictions for joint replacement operations. The bad news is that they are still distressingly common and keep many people of size from accessing the surgery and improvement in pain and function. I have a new blog post series coming up on this soon. Stay tuned.

  11. Here’s a study that found that outcomes were actually WORSE in those who had weight loss surgery before their joint replacement: https://www.ncbi.nlm.nih.gov/pubmed/27179771

    This may be because of malnutrition from malabsorption or chronic calorie restriction. Research shows clearly that malnutrition is a far greater risk factor for poor outcomes after joint replacement than obesity: https://www.ncbi.nlm.nih.gov/pubmed/28167877

    Here is the link to part 1 of my series on BMI and Joint Replacement: https://wellroundedmama.blogspot.com/2017/07/obesity-and-joint-replacement-part-1.html More installments to come.

  12. i’m so grateful for the healthcare system in my country. there is no such fatphobe bullshit here. i always take it for granted, but now i understand how lucky am i.

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