Bariatrics and Orthopedics Work Together in SWIFT Study: Evaluating Impact of Surgical Weight Loss on Joint Disease in Obese Patients

A Message from Dr. Christopher Still

Christopher Still, DO, FACN, FACP, Co-Clinical Editor, Bariatric Times; Medical Director for the Center for Nutrition and Weight Management, and Director for Geisinger Obesity Research Institute, Geisinger Medical Center, Danville, Pennsylvania. Dr. Still is also a board member of the Obesity Action Coalition, Tampa, Florida.

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Dear Readers,
I’d like to wish everyone a happy and healthy 2016. In January 2015, I discussed how to help your patients keep their resolutions to lose weight and/or get back on track with their nutrition, fitness, and appointment regimens. I feel this message can be applied at every start to a new year and encourage you to go back and re-read it for some tips on how you can motivate your patients to long-term success.

This year I am excited to be starting work on a new clinical trial: Surgical Weight-loss to Improve Functional status Trajectories following Total Knee Arthroplasty or SWIFT for short. It is a multi-year clinical study that will involve collaboration between Geisinger’s Obesity Institute, Orthopedic Institute, and Minimally Invasive and Bariatric Surgery Department. In addition, Geisinger will partner with clinical research teams at Cleveland Clinic-Florida, Stanford University, New York University, and the University of Virginia. The study is being funded by a grant from Ethicon Endo-Surgery, Inc.

We applied for the grant to study this area because we know in the big picture, as body mass index (BMI) increases, so too does the incidence of degenerative joint disease at a younger age, especially of the knees. Additionally, there are no controlled studies comparing arthroplasty before versus after surgical weight loss and retrospective studies suggest that surgical weight loss may improve arthroplasty outcomes.
Individuals with a BMI of 40kg/m2 or more have a higher incidence of degenerative joint disease requiring joint replacement surgery. We have seen patients who need joint replacement surgery, but are told that they must lose weight first because of the dangers of operating at the patient’s present BMI. Orthopedic centers are often reluctant to operate due to the higher possibility of complications post surgery, such as infection, and failure (i.e., patients continue to have problems even after surgery). For instance, a study by Kerkhoffs et al indicated higher complications post joint surgery from obesity.[1] This creates a barrier of care that we are trying to bridge with more research surrounding the benefits of weight loss in this unique patient population.
The eligibility criteria for the SWIFT study is as follows: individuals requiring a knee replacement to treat Non-inflammatory Degenerative Joint Disease (NIDJD) and have either 1) a BMI of 40kg/m2 or more or 2) a BMI between 35 and 40kg/m2 with at least one comorbidity. As you can see, the BMI criteria is the same as used to determine eligibility for bariatric surgery. We will be examining two groups: Group 1, the control group, will undergo the total knee arthroplasty (TKA) without a surgical weight loss intervention and Group 2, the treatment group, will undergo bariatric surgery (laparoscopic sleeve gastrectomy [LSG] or Roux-en-Y gastric bypass [RYGB]) before being reconsidered for TKA.

We are aiming to enroll 50 patients in each group at each institution for a total of 500 study participants. Individuals in the control group will be followed for two years after TKA. Individuals in the treatment group will be evaluated 9 to 12 months after bariatric surgery to determine if TKA is still needed, then followed for an additional two years (regardless of whether the TKA is performed or not).

We believe the study will show that the need for TKA will either be delayed or eliminated in many individuals after achieving weight loss via bariatric surgery. Patients in the treatment group who still need TKA after bariatric surgery will be further studied against the individuals with a higher BMI in the control group to compare safety and efficacy of the procedure in patients after weight loss.
We believe this trial will highlight yet another benefit of weight loss via bariatric surgery and also improve care for patients presenting to orthopedics. We hope it creates awareness among patients who need TKA but have been denied because of their weight. Bariatric surgery is an option that may hold the key for this patient population and we hope to engage them with positive outcomes from this trial. In addition, we believe this study will help further establish another opportunity for us to treat individuals with obesity.

Our team at Geisinger is honored to have been selected as the primary site for this study and is ready to begin work. Personally, I’m excited to be working with some of my bariatric colleagues: Drs. Anthony Petrick, Raul Rosenthal, John Morton, Manish Parikh, Christine Ren-Fielding, Peter Hallowell, and Bruce Schirmer. Teams at each site have worked great together so far in the process. Everyone has been very insightful and active in the preliminary stages and I think it’s going to be a lot of fun to continue working together.

We are also excited to be working with our colleagues in orthopedics at each institution. I think we are going to learn a lot from each other.

To learn more about the SWIFT study, read this month’s Research Bites column on page 12.

Sincerely,

Christopher Still, DO, FACN, FACP

References
1.    Kerkhoffs GM, Servien E, Dunn W, Dahm D, Bramer JA, Haverkamp D. The influence of obesity on the complication rate and outcome of total knee arthroplasty: a meta-analysis and systematic literature review. J Bone Joint Surg Am. 2012;94(20):1839–1844.

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Category: Editorial Message, Past Articles