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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 techniques were used to control for age and American Society
were considered obese. Those with a BMI less than 30 were of Anesthesiologists (ASA) score. All analyses were performed
considered nonobese. Age, gender, injury characteristics, in SPSS (version 21.0; IBM Corporation, Armonk, NY).
laboratory values, hospital stay, length of mechanical venti-
lation, and transfusion records were obtained from electronic
hospital records. RESULTS
Complications were adjudicated by a panel of physi- Three hundred seventy-six patients (264 men and 112
cians not involved in other data collection or analysis. Deep women) were treated for 394 fractures of interest, and 158 of
venous thrombosis (DVT) was diagnosed by positive duplex them (42.0%) had a BMI greater than 30 and were considered
ultrasound proximal to the knee. Pulmonary embolism was obese (Table 1). The mean BMI for the obese group and the
diagnosed by computed tomography. Pneumonia was nonobese group were 36.8 6 6.8 (range, 30.062.9) and 24.7 6
dened as culture-positive sputum with new persistent 3.2 (range, 16.429.9), respectively (P , 0.0001). Thirty-
inltrate on chest radiograph, a temperature .388C, and seven patients had BMI .40 (9.8%). Female patients were
a white blood cell count .10,000/mL.15 Acute respiratory more likely to be obese: 38.0% of obese patients were women
distress syndrome was dened as an acute onset of bilateral versus 26.1% of nonobese patients (P = 0.003). Mean age of
inltrates on chest radiography and a PaO2:FiO2 ratio of less obese patients was also higher than nonobese patients (44.7 6
than 200 mm Hg for 4 consecutive days in the absence of 16.3 years vs. 36.4 6 16.5 years; P , 0.001). Mean ISS was
cardiogenic pulmonary edema.16 Acute renal failure (ARF) 28.1 6 12.7 for obese patients and 26.1 6 11.4 for nonobese
was dened as 50% increase in creatinine from baseline patients (P = 0.12). Obese patients were twice as likely to
level.17 Sepsis was dened as infection manifested by at have diabetes mellitus (P , 0.0001).
least 2 of the following: temperature .388C or ,368C, heart Injuries to other body systems are listed in Table 1. No
rate .90 beats per minute, respiratory rate .20 breaths differences were seen in the presence or severity of injuries to
per minute or PaCO2 , 32 mm Hg, and white blood cell the head, chest, or abdomen, between obese and nonobese
count .12,000/mm3, ,4000/mm3, or .10% immature patients. Fractures of interest are also noted in Table 1. Non-
(band) forms.18 MOF was dened as failure of 2 or more obese patients were more likely to be treated for femoral
organ systems.19 fractures, occurring in 48.2% versus 38.0% (P = 0.049).
Independent samples t tests were used to compare means There was also a trend for obese patients to be more likely
of continuous and ordinal variables between obese and non- to be treated for pelvic ring injuries, occurring in 23.4% ver-
obese patients. P values less than 0.05 were considered to rep- sus 16.1% (P = 0.07).
resent a signicant difference. For variables with Levene Test Time from the injury until denitive xation of the
for Equality of Variances greater than 0.05, equal variance was fractures of interest was studied (Table 2). Mean time to
not assumed. Pearson x2 test less than 0.05 was considered to xation for obese patients was 34.9 hours after injury versus
represent a signicant difference in categorical variables 23.7 hours for nonobese patients (P = 0.03). In other words,
between obese and nonobese patients. Multivariate regression obese patients waited a mean of 47% longer to have their
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Childs et al J Orthop Trauma Volume 29, Number 11, November 2015
fractures stabilized. Reasons for all surgical delays were P = 0.07). No differences in the rates of pulmonary compli-
noted. Seventy-six of all 376 patients had denitive xation cations, MOF, and death were noted between the 2 groups.
more than 36 hours after injury (20.2%). Thirty-one of 41 Post hoc power analysis revealed our study to be underpow-
(76%) of the delayed surgeries in obese patients were due ered to identify a difference between obese and nonobese
to surgeon choice, whereas 24 of the 35 delays (69%) in patients for comparisons of pulmonary complications, MOF,
nonobese patients were by surgeon choice (P = 0.02). Mean or mortality, as these would require study of 412, 3644, and
timing of fracture xation was not different between obese 3233 patients, respectively.
and nonobese patients when those due to surgeon choice were Eight patients had early failure of xation (2.1%),
excluded: 19.2 hours for obese patients versus 18.3 for non- requiring revision surgery. This occurred more often in obese
obese (P = 0.67). patients (3.80% vs. 0.92%, P = 0.056). However, rates of
Despite no differences in ISS or in injuries to other nonunion were not different when the 2 groups were com-
body systems, longer hospital stays were observed in obese pared. Nonunions occurred overall in 12 patients (3.2%).
patients (see Table, Supplemental Digital Content 1, http:// We further divided patients into groups of increasing
links.lww.com/BOT/A334), which compares length of stay BMI (Table 4). Obese patients were subdivided into three
and ventilation times in obese and nonobese patients. Obese BMI groups: 3034.9, 3539.9, and greater than 40. The
patients spent more days in the ICU (7.06 6 9.2 vs. 5.25 6 frequency of some complications increased as BMI increased
8.6, P = 0.054), more days on mechanical ventilation (4.92 6 from normal (,25) to overweight (2529.9) and to obese.
7.8 vs. 2.90 6 6.2, P , 0.01), and more total days in the This is further depicted in Figure 1. Patients with BMI over
hospital (12.3 6 9.5 vs. 9.79 6 8.8, P , 0.01). 40 also had longer mechanical ventilation times versus nor-
A total of 106 patients developed 150 early complica- mal BMI patients (5.51 days vs. 2.78, P = 0.02) and a trend
tions (Table 3). Obese patients were more likely to have toward longer total length of hospital stay (14.0 days vs. 10.9,
complications (38.0% vs. 28.4%, P = 0.03). Thirty patients P = 0.08). Mean length of surgery was also an hour longer in
had soft tissue infections (7.98%), and 6 of them developed patients with BMI over 40 versus those with normal BMI
sepsis. Obese patients were more likely to develop infections (4:03 vs. 3:07, P = 0.02).
(11.4% vs. 5.50%, P = 0.04), with rates of sepsis in 8.28% Controlling for the signicantly higher mean age of the
versus 4.13% (P = 0.09) for obese versus nonobese patients, obese population, increasing BMI was a signicant predictor
respectively. ARF was signicantly more frequent in obese of increased duration of surgery (b = 1.35, t(374) = 2.575, P =
patients (5.70% vs. 1.38%, P = 0.02), and there was a trend 0.01, r2 = 0.02), increased length of hospital stay (b = 0.120,
toward more DVTs in obese patients (4.43% vs. 1.38%, t(374) = 2.298, P = 0.017, r2 = 0.017), and increased length of
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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 = of ASA score, the concurrent adjustment of ASA score and
0.024, r2 = 0.026). BMI was not an signicant predictor of age is not reported.
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 DISCUSSION
BMI unit increase in the odds of infection (P = 0.181), sepsis From 1991 to 1998, the prevalence of obesity in the
(P = 0.153), pulmonary embolism (P = 0.676), pneumonia United States increased from 12% to 17.9%. This trend was
(P = 0.290), acute respiratory distress syndrome (P = 0.496), reected across all states, age groups, education levels, and
MOF (P = 0.512), death (P = 0.200), implant failure (P = sexes.2,20,21 Obesity has continued to climb and is a major
0.176), pulmonary complications (P = 0.306), or complica- public health issue, as it is widely and credibly linked to
tions (P = 0.148) regardless of age or ASA score. Odds of chronic heath conditions including heart disease, diabetes,
developing ARF increased by 7.5% per unit BMI controlled and premature mortality.20,22 If current obesity trends and
for ASA score (P = 0.010) or by 7.0% controlled for age (P = health care costs continue to progress at the same rate, the
0.023). The odds of developing a DVT increased by 9.1% per majority of adults in the United States would be obese by
BMI unit controlled for ASA score (P = 0.005) or 10.1% 2030, and obesity-related health care costs would double
when controlled for age (P = 0.003). Notably, due to the every decade, reaching 860 billion dollars by 2030.23 These
effects of multicollinearity, because age is a key determinant trends are reected in our study with 42% of our cohort found
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Childs et al J Orthop Trauma Volume 29, Number 11, November 2015
in the obese group, and obese patients were twice as likely to The strengths of this study are numerous. The data were
have a diagnosis of diabetes mellitus. This nding is espe- collected prospectively over a short period of time with strict
cially salient, as recent studies have shown that obesity not oversight of the data, ensuring accuracy. A large proportion
only contributes to chronic systemic illness but also can pose of our study cohort was obese, allowing us to have narrow
problems for orthopedic patients. condence intervals. Furthermore, the severity of injury in
Similar to our ndings, other studies have shown longer our patients was consistent with other studies investigating
surgical times and longer hospital stays in obese patients24,25 obesity in general trauma, allowing us to make direct
as well as more frequent complications for elective orthopedic comparisons to the existing literature. Weaknesses include
patients.2631 Previous studies of various groups of trauma a disparity in age and gender in the obese and nonobese
patients have described an association between obesity and populations. Some of these differences may be unavoidable
complications,4,710,32,33 specically sepsis,4,6 other infec- due to the direct relationship between body weight and age,
tions,4,10 organ failure,5,6 and death.68 It is believed that dia- both increasing over time (0.093 BMI points per year; r2 =
betes mellitus and potential for poor glycemic control may 0.041, b = 0.093, P , 0.01).20,22 We performed regression to
contribute to septic complications in diabetic patients.8,26,27,33 account for age, and BMI remained an independent predictor
Other studies have reported diabetes in association with obe- of these outcomes. However, our sample size was not large
sity, similar to our data.8,9,17,26,27,33 Consistent with these stud- enough to detect statistical differences between obese and
ies, we identied more complications in obese patients. nonobese groups for certain comparisons, such as differences
Signicantly, more infections and renal failure were found. in pulmonary complications, MOF, or mortality, as we would
More DVTs were identied when controlled for age or ASA have required more than 3000 patients.
score. Corresponding increases in length of hospital stays and Optimization of care for obese orthopedic patients is
mechanical ventilation times were also detected in our obese critical for trauma centers. Obese patients form a substantial
patients. This is similar to other studies on blunt general portion of the patient population in the United States, and the
trauma patients.4,68 percentage of patients who are obese is likely to increase in
Considering the higher complications and increased the future. It is clear that care of obese patients raises unique
utilization of resource-intensive treatment measures, we challenges. Elucidating the risks associated with treating
anticipate higher costs of care although our study did not obese patients is necessary to determine if action can be
specically measure costs.34 We also reported signicantly taken to optimize treatment not only to avoid costs associated
longer surgical times and longer times on mechanical ven- with increases in ICU days, mechanical ventilation times, and
tilation in our obese patients, both of which would be asso- infections and other complications but also to benet these
ciated with higher costs of initial care. These ndings are often challenging patients.
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 REFERENCES
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J Orthop Trauma Volume 29, Number 11, November 2015 Effects of Obesity on Hospital Course
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