The Centers for Disease Control and Prevention report that more than 40 percent of Americans are obese, a rate that has continued to increase over time. The increasing prevalence of obesity has not only resulted in numerous negative health effects for patients but also placed significant strain on the healthcare professionals who treat them. It is well established that nurses and nursing assistants regularly sustain work injuries due to patients’ obesity. However, similar strain placed on orthopaedic surgeons during procedures has been overlooked.

Occupational injury risk in orthopaedic surgery
A prospective study used physiologic metrics to evaluate cardiovascular strain in surgeons performing total hip arthroplasty, demonstrating statistically significant increases in surgeon hourly energy expenditure, mean heart rate, and stress index (a measure of sympathetic activity) with increasing patient body mass index (BMI). The increases occurred regardless of surgical approach, number of assistants, or time of day.

Literature also suggests a high prevalence of work-related musculoskeletal disorders among orthopaedic surgeons. A systematic review demonstrated that career prevalence of work-related musculoskeletal injuries in orthopaedic surgeons ranged from 37 percent to 97 percent, with 9 percent to 33 percent taking a leave of absence, requiring practice restriction, or retiring early. The most common work-related musculoskeletal injuries are to the head or neck, back, forearm and wrist, or hand.

Fifteen percent of respondents in an AAOS member survey reported a work-related injury at some point during their careers as orthopaedic surgeons. A small number (3.7 percent) of respondents filed disability claims, and 33.9 percent of those who claimed disability retired early. The high incidence of musculoskeletal disorders among orthopaedic surgeons may be related to the highly repetitive motions, physical labor, and poor ergonomics associated with orthopaedic procedures. Although not directly evaluated by these studies, the increased incidence of obesity among patients could reasonably contribute to the overall strain on orthopaedic surgeons as well. The physical toll related to workplace injuries can result in decreased work satisfaction, increased stress, and decreased career longevity.

Strategies to avoid injury
The National Institute of Occupational Safety and Health recommends a 35-pound lifting limit for patient-handling activities, a threshold frequently exceeded by healthcare workers. For example, one lower extremity during total hip arthroplasty could exceed 60 to 70 pounds in an obese patient. Safe patient handling and mobilization (SPHM) programs are procedures and assistive technologies aimed at ensuring that patients are mobilized safely while minimizing injury to healthcare workers. A meta-analysis evaluating injury rates before and after the implementation of SPHM programs demonstrated a 56 percent decrease in injury risk related to patient handling. SPHM protocols and assistive devices incorporated in the OR could further reduce injuries sustained by surgeons when they are performing procedures on obese patients. Strategies could include positioning teams, bolsters, and other specialized equipment to assist in positioning, exposure, and limb manipulation.

A retrospective study demonstrated that although obese patients undergoing total knee arthroplasty had a higher rate of wound complications when compared to controls, obese patients demonstrated substantial improvement in functional scores and patient satisfaction. Clearly, this patient population can greatly benefit from surgical intervention, but strategies need to be developed and implemented to protect and properly compensate surgeons and other healthcare workers who risk injury when managing obese patients.

Robotic-assisted surgery may be one approach to reduce the physiologic burden of operating on obese patients. A prospective study compared the physiologic impact on surgeons of robotic-assisted versus conventional total knee arthroplasty. The robotic-assisted group demonstrated significantly lower calorie expenditure, mean heart rate, and minute ventilation when compared with the conventional group. The robotic-assisted group also had a lower mean degree of lumbar flexion compared with the conventional group.

A multifaceted approach is needed to reduce obesity-related increased demand on orthopaedic surgeons. Implementation of SPHM programs, as well as ergonomically designed surgical instruments and retractors, could help reduce the strain on surgeons. Management of obese patients continues to be an occupational hazard to healthcare workers. Although preoperative optimization strategies such as bariatric surgery and GLP-1 agonists are becoming more readily available, a significant proportion of orthopaedic surgery patients remain obese. A greater emphasis on preoperative weight loss would significantly help patients as well as surgeons.

This article was submitted on behalf of the AAOS Committee on Healthcare Safety. The authors would like to thank Shivam Srivastava for help with the literature search and preliminary manuscript.

David Hein, MD, is an orthopaedic surgery resident at the Michigan State University–McLaren Health Care program in Flint, Michigan.

Ajay Srivastava, MD, FAAOS, is an adult reconstruction surgeon and director of the McLaren Flint orthopaedic surgery residency program at McLaren Flint Medical Center and Hurley Medical Center in Flint, Michigan.

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