Joint Replacement in the Overweight Patient

Abstract

During the 1990s, some cardiac surgeons were pilloried for suggesting that coronary artery grafting should be withheld from patients who continued to smoke. This attitude was deemed unacceptable. Doctors should advise on risk factors and treat disease, but not withhold therapy on account of an individual patient's life-style. Some Suffolk Primary Care Trusts (PCTs) have, apparently, restricted funding for arthroplasties to those with a body mass index (BMI) of less than 30 kg/m2. The paper from Davies and Porteous extrapolates local data concerning those in whom surgery is withheld to incorporate numbers that would be affected if this policy was instituted nation-wide. Liz Symonds writes for the patient. For many, losing weight is not easy, especially for those living in poor circumstances where access is somewhat difficult to a personal trainer and a Mediterranean diet. If health rationing based on the fortunes of PCTs is to occur, (which it undoubtedly will) should not PCTs engage the local population in the debate and give some lead time? If a PCT opines that treatment is to be denied to patients who do not address their own ‘poor’ life-styles (and perhaps that is the responsibility of these guardians of HM Treasury money), what other groups may be similarly affected – drug abusers, alcoholics, multipartner gays with HIV, smokers with COPD – all consume expensive and repeated visits for hospital treatment, so where does this stop? Of 20th century surgical success stories, arthroplasty must count for one of the most frequently performed techniques which have resulted in improved quality of life for so many patients. Is there evidence that this surgery does not improve the quality of life of the obese? Health rationing, not only by postcode, but also by life-style may be the future face of health commissioning: currently it is by stealth and not by public open debate. Thomas CB Dehn Consultant Surgeon