The use of local adiposity as a proxy for obesity in primary total hip arthroplasty: A systematic review

John J. Heifner; Yitzak M. Fox; Philip A. Sakalian; Arturo Corces

doi:10.1016/j.jor.2023.03.012

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38 (); 79-84

doi:

10.1016/j.jor.2023.03.012

The use of local adiposity as a proxy for obesity in primary total hip arthroplasty: A systematic review

John J. Heifner^a,, Yitzak M. Fox^b, Philip A. Sakalian^b, Arturo Corces^b

a Miami Orthopaedic Research Foundation, Coral Gables, FL, USA

b Larkin Hospital Department of Orthopaedic Surgery, Coral Gables, FL, USA

∗Corresponding author: John J. Heifner. johnjheifner@gmail.com

Received: 2023-3-14, Accepted: 2023-3-25, Published: 2023-3-27

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Preoperative optimization of obese patients is a critical component of risk stratification in primary total hip arthroplasty (THA). Body mass index is ubiquitously utilized as a proxy for obesity due to its ease of attainment and simplistic interpretation. The use of adiposity as a proxy for obesity is an emerging concept. Local adiposity provides insight into the magnitude of peri-incisional tissue and has demonstrated an association with postoperative complications. Our objective was to review the literature to determine if local adiposity is a reliable predictor for complications following primary total hip arthroplasty.

In keeping with the PRISMA guidelines, a database search of PubMed was conducted for articles which reported on the relationship between quantified measures of adiposity at the hip and rates of complication following primary THA. Methodological quality was assessed using GRADE and risk of bias using ROBINS-I.

A total of six articles (N = 2931) met the inclusion criteria. Local adiposity at the hip was measured on anteroposterior radiograph in four articles and was measured intraoperatively in two. Across four of the six articles, adiposity was significantly associated with postoperative complications including prosthesis failure and infection.

The use of BMI as a predictor for postoperative complication has been fraught with inconsistency. There is momentum for adiposity to be used as a proxy for obesity in preoperative THA risk stratification. The current findings demonstrated that local adiposity may be a reliable predictor for complications following primary THA.

Keywords

Adiposity

Hip arthroplasty

Infection

Obesity

PJI

Total hip

Show Related Articles from PubMed

1 Introduction

Primary total hip arthroplasty (THA) is one of the most successful procedures in orthopedic surgery.¹ The intended result of THA - pain relief and restoration of function - has been demonstrated across short and long terms of follow up.² Estimates forecast a substantial increase in primary THA utilization by 2030,³ and revision THA is projected to follow a similar trajectory.⁴

Rates of complications following primary THA are highly variable in part due to the criteria used to define a complication and the temporal points of reporting.⁵^,⁶ Infection and prosthesis dislocation are the most common complications following primary THA.⁵ Despite increased attention and improved methods to reduce the risk of infection, the rates of PJI have not declined.⁷ Further, with the increasing incidence of primary THA, the economic burden of PJI is expected to rise.⁸

By the end of the current decade, over 50% of primary THA patients may be classified as obese.⁹ Preoperative optimization of obese patients is a critical component of risk stratification. Body mass index (BMI) is ubiquitously utilized as a proxy for obesity due to its ease of attainment and simplistic interpretation. However, BMI has demonstrated variable performance in this role.¹⁰ Notably, this practice has resulted in restricted access to the treatment.¹¹^,¹² There is established agreement on the need for preoperative risk stratification in obese patients. But it is crucial to reliably and accurately characterize the risk of complications.

Soft tissue thickness has been identified as a reliable and reproducible predictor for postoperative complication following laparoscopic gastrectomy,¹³ cervical fusion,¹⁴ sternal reconstruction,¹⁵ and colorectal surgery.¹⁶ Frenkel et al.¹⁷ reported a significant association between increased fat thickness and postoperative infection in patients undergoing hip fracture surgery. Percent body fat was determined to be a significant predictor for complications following total joint replacement.¹⁸ Further, Waisbren et al.¹⁹ concluded that percent body fat was a more sensitive and precise measure of infection risk following elective surgery. Although adiposity has gained momentum across surgical specialties as a predictor for postoperative complications, the aggregate findings for primary THA are unknown. Local measures of adiposity provide information about the mechanical conditions at the surgical site and the systemic physiologic conditions of the patient. These variables have the potential to impact the risk of complication due to increased surgical time and tissue insult, and suboptimal immune function. Improved understanding for risk stratification in these cases has substantial medical and economic implications.

The primary objective was to review the literature to determine if local adiposity is a reliable predictor for complications following primary total hip arthroplasty. The secondary aim was to aggregate the findings that compared the prognostic capacity for complication between BMI and adiposity. We hypothesized that although adiposity will function as a reliable predictor for complications following primary total hip arthroplasty, the heterogeneity of methods will yield inconsistent results in aggregate.

2 Methods

2.1

2.1 Search strategy

In keeping with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a database search of PubMed was conducted on 01.26.2023. The Population, Intervention, Comparison and Outcome (PICO) characteristics for eligibility were as follows: patients over 18 years of age who underwent a primary total hip arthroplasty, reporting of intraoperative or perioperative measurement of adiposity at the hip, and determination of the relationship between adiposity and postoperative complications. The following search terms were used: fat thickness, adiposity, AND total hip arthroplasty, OR replacement, soft tissue thickness AND hip. The return for each search iteration was evaluated by two authors to form the final group of included articles.

2.2

2.2 Eligibility criteria

Inclusion required reporting on primary THA and the relationship between quantified measurement of local adiposity at the hip and rates of complication (as individually defined by the published article). Further, where possible rates of infection, reoperation and revision were collected and analyzed as a subset of complication. Excluded articles were those that did not provide quantified measurement of local adiposity in primary THA, and those that did not analyze the relationship between local adiposity and complications - whether in general or within a specified subset of complication.

2.3

2.3 Data collection

The variables gathered from each article were sample size, term of follow up, the case definition for complication (in general or within a defined subset), the specific criteria for measuring local adiposity at the hip, and the calculated association between complication (in general or within a defined subset) and local adiposity.

2.4

2.4 Risk of bias assessment

The Cochrane ROBINS-I (risk of bias in non-randomized studies of interventions) was used to appraise the risk of bias for the following domains: confounding, selection of participants, classification of interventions, deviation from intended interventions, missing data, measurement of outcomes, and selection of reported result.²⁰ A level of risk (low, moderate, serious) was assigned to each domain then collectively for the overall risk of bias for each included article.

2.5

2.5 Quality assessment

The GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework was used to appraise the quality of evidence.²¹ The phase of investigation was identified as the starting point for evidence evaluation. For each outcome of interest, downgrading the quality of evidence due to serious limitations was based on the following factors: limitations, inconsistency, indirectness, imprecision, and publication bias.

2.6

2.6 Data synthesis

Where possible, homogenous complication data were grouped for analysis. In the case of heterogenous data, results were described within the context of reporting without aggregation. Statistical significance was defined as p < 0.05.

3 Results

3.1

3.1 Search results

The database search returned 660 articles, with 319 being evaluated by abstract and title following early exclusions of duplications and irrelevancy (Fig. 1). Articles which did not quantify a measure of adiposity at the hip and those which did not analyze the relationship between adiposity and postoperative complications were excluded. A total of six articles (N = 2931) met the inclusion criteria and were included for analysis (Table 1). There were no disagreements among the authors for the applied inclusion criteria.

Flowchart detailing the database search and article identification with pertinent exclusions.

Table 1 Included articles which analyzed the association between local adiposity and complications following primary total hip arthroplasty.

Study	LOE^a	N	Follow up^a	Outcome/approach^a	Measurement parameters^a	Findings
Intraoperative measurement
Mayne, 2020²³	IV^b	1220	16 months (mean)	Surgical complication (dislocation, infection, periprosthetic fracture, wound dehiscence) @ minimum 12 months, PA	Peritrochanteric fat depth (PFD) - most prominent aspect of the GT to the skin	There was no increase in infection risk with increased PFD. BMI ≥40 had a significantly increased risk of infection
Sprowls, 2020²²	IV^b	124	90 days	90-day complications (wound, PJI, return to the OR, other), DAA/PA	Incisional site fat thickness (FT) at the midpoint of the incision, from the superficial extent of the fat to the TFS (DAA) or ITB (PA)	Anterior FT was significantly associated with wound complications, and lateral FT with PJI
Anteroposterior measurement
Bell, 2019²⁴	III^c	78	90 days	90-day reoperation for infection/wound complication, matched cohorts, PLA	Peritrochanteric fat thickness (PFT) - sourcil to the skin, tip of the GT to the skin, lateral aspect of the GT to the skin.	There was no association between the 3 measures of PFT and complications
Sprowls, 2020²⁶	IV^b	1110	NR	Complications (SSI, deep infection, noninfectious surgical, revision surgery, medical), LA	Soft tissue thickness (STT) - most lateral point on the GT to the skin	STT was significantly associated with greater risk of SSI, deep infection, and revision surgery, on multivariable analysis
Fernandez, 2021²⁵	III^c	78	1 month	1-month PJI, matched cohorts, PLA	STT - tip of the GT to the skin	Independent and significant association between a large STT and risk of acute PJI
Sezgin, 2021²⁷	IV^b	321	1 year	1 year failure (reoperation), ALA	Fat thickness ratio (FTR) - ratio of fat to femoral diameter - fat was measured from the lateral aspect GT to skin, the diameter of the femur was measured just inferior to the LT (both measures were perpendicular to the axis of the femur)	High FTR was significantly associated with failure, on univariate and multivariate analysis

a LOE - level of evidence.

b Retrospective case series.

c Retrospective cohort.

3.2

3.2 Bias and quality assessment

In all articles, at least one domain was at moderate risk of bias which indicates that each study cannot be considered comparable to a well-performed randomized trial (Table 2).²⁰ Across all articles, there were no domains judged to be at a critical risk of bias.

Table 2 Cochrane risk of bias ROBINS-I (risk of bias in non-randomized studies of interventions) for included articles with green indicating low risk, yellow indicating moderate risks, and red indicating serious risk.

Within the GRADE framework, all articles were classified as phase I investigations which indicates an emerging topic with weaker evidence (Table 3). The outcomes of interest were infection/acute PJI (prosthetic joint infection), 90-day complication/reoperation, and construct failure. All articles were deemed to have serious limitations for indirectness and imprecision which downgrades the quality of the evidence. There were no downgrades for study limitations and publication bias.

Table 3 An adapted Grading of Recommendations Assessment, Development and Evaluation (GRADE) summarization for a systematic review of local adiposity used as a proxy for obesity in primary total hip arthroplasty.

Outcome	Phase of investigation	Limitations	Inconsistency	Indirectness	Imprecision	Publication bias
†Infection/acute PJI*	Explanatory (phase I)	✗	✗	✓	✓	✗
‡90-day complication/reoperation	Explanatory (phase I)	✗	✗	✓	✓	✗
§Construct failure	Explanatory (phase I)	✗	Unclear	✓	✓	✗

3.3

3.3 Study characteristics

The reported approaches to the hip were direct anterior,²² posterior,²²^,²³ posterolateral,²⁴^,²⁵ lateral,²⁶ and anterolateral.²⁷ Local adiposity at the hip was measured on anteroposterior radiograph in four articles,^24–27 and measured intraoperatively in two articles.²²^,²³ Two articles reported 90-day follow up data for infection,²² and reoperation for infection/wound complication.²⁴ One article reported acute PJI within four weeks postoperatively.²⁵ Two articles reported one year data for reoperation or failure²⁷ and complications.²³

3.4

3.4 Individual study results

Sprowles et al.²² reported a consecutive series (N = 124) of primary THA with one surgeon performing a posterior approach (PA) and another surgeon performing a direct anterior approach (DAA). Intraoperative fat depth was measured in the cranial-caudal dimension from the fascia of the tensor fascia latae (DAA) and the iliotibial band (PA) to the superficial extent of the fat layer. Fat depth was also measured on anteroposterior radiograph as the horizontal distance from the lateral most edge of the greater trochanter to the skin. Wound complications were defined as superficial infection, wound dehiscence, delayed healing, cellulitis, seroma, or hematoma. Prosthetic joint infection (PJI) was defined in accordance with well accepted guidelines. Results showed that anterior fat depth was significantly associated with wound complications, PJI was significantly associated with BMI (p = 0.0065) and lateral fat depth (p = 0.0129). Although no outcome variable was associated with radiographic fat depth, this measure of adiposity was strongly correlated with intraoperative anterior and lateral fat depth.

Bell et al.²⁴ gathered a cohort of primary THA performed via posterolateral approach who returned to the operating room within 90 days of the index procedure for wound complication or infection. This cohort was matched with age, gender, BMI, and American Academy of Anesthesiologists Score to one without 90-day return to the operating room for wound complication or infection (N = 78). Fat thickness was measured on anteroposterior radiograph from the following positions: distance from the sourcil to the skin surface, from the tip of the greater trochanter to the skin surface and from the lateral aspect of the greater trochanter to the skin surface. Results demonstrated that fat thickness was not associated with infection nor wound complications.

Sprowles et al.²⁶ reported on a consecutive series (N = 1110) of primary THA cases performed using a posterior, lateral and anterolateral approaches. Outcomes were grouped into surgical site infection which were defined as superficial and deep wound infection which was defined using the American Academy of Orthopedic Surgeons guidelines. Soft tissue thickness was measured on anteroposterior radiograph as the horizontal distance from the most lateral point on the greater trochanter to the skin edge. Across univariate and multivariate analysis, there was a significant association between soft tissue thickness and risk of surgical site infection and deep infection. BMI was significantly associated with deep infection on univariate analysis.

Sezgin et al.²⁷ evaluated subcutaneous fat thickness in 321 cases of primary THA for the indication of osteoarthritits, utilizing an anterolateral approach. Failure of the operation was defined as any reoperation within the first year following the index procedure. Subcutaneous fat thickness was measured on anteroposterior radiograph as the distance between the most lateral point on the greater trochanter to the skin, along an axis perpendicular to the anatomical axis of the femur. This measure was divided by the diameter of the femoral diaphysis at the level just inferior to the minor trochanter to yield the ratio of fat thickness. Females had a significantly greater mean fat thickness ratio (p = 0.001) compared to males. Prosthesis failure was significantly associated with fat thickness ratio.

Mayne et al.²³ intraoperatively measured fat depth on 1220 consecutive primary THAs using a posterior approach. Follow up was collected at a minimum of 12 months, and a mean of 16 months. Complication was defined as dislocation, infection, periprosthetic fracture, and wound dehiscence. Infection was defined as those requiring repeat hospitalization for this indication and wound dehiscence was defined as those requiring reoperation. Fat depth was measured from the most prominent part of the greater trochanter to the skin, along a vertical axis. Fat depth and BMI were found to have a weak correlation for males and females. Patients in the upper quartile of fat depth were at no greater risk for complication (p = 0.851) compared to those in the lower quartile of fat depth. Patients with BMI ≥40 had a significantly increased risk on complication (OR 5.77, p = 0.0001) compared to patients with BMI <40.

Fernandez et al.²⁵ compared a cohort of primary THAs that were diagnosed with acute PJI (within four weeks postoperatively) to a matched cohort of without acute PJI using age, gender, and date of index procedure. All cases (N = 78) were performed using a posterolateral approach. Soft tissue thickness was measured on anteroposterior radiograph as the distance from the tip of the greater trochanter to the skin, along a line perpendicular to the femoral diaphysis. Soft tissue thickness demonstrated a moderately positive significant relationship with BMI. Soft tissue thickness was independently associated with acute PJI, and there was a significant association between acute PJI and soft tissue thickness measures greater than the median. On multivariate regression analysis, there was no association between acute PJI and BMI.

4 Discussion

Obesity is a critical factor in the evaluation of primary THA patients. Body mass index is commonly used as a proxy for obesity to stratify risk of postoperative complication. The American Academy of Orthopaedic Surgeons defines the acceptable threshold for elective safe surgery to be BMI <40. Subsequently, BMI has been used to restrict access to THA.²⁸^,²⁹ Whether this practice is efficacious is currently debated.³⁰

The use of adiposity as a proxy for obesity is an emerging concept as illustrated by all included articles being published between 2019 and 2021. The quality of evidence is limited in part due to heterogeneity of the methodologies which prevented quantified aggregate analysis. However, the qualitative findings are compelling, with four of the six articles reporting adiposity being significantly associated with postoperative complications including prosthesis failure and infection. Sprowles et al.²⁶ reported a significant relationship between adiposity and infection multivariable analysis. Within the same report, BMI was significantly associated with infection on univariate analysis but did not fit the criteria for multivariable analysis. Mayne et al.²³ reported that a high BMI had a significantly increased risk of complication. In contrast, Fernandez et al.²⁵ reported no association between infection and BMI. These aggregate results indicate that local adiposity may be a reliable predictor for complication following primary THA.

BMI provides general insight into body size but does not account for the distribution of size. Measurement of local adiposity demonstrates the magnitude of peri-incisional tissue. The mechanisms for complication risk in the presence of increased adiposity include greater tissue insult, lengthened surgical time, the hypoxic environment that characterizes adipose tissue, and the mechanical difficulties in exposure that can impact bone preparation and prosthesis position. Further, measures of adiposity provide insight into the potential for systemic metabolic dysfunction that is attributable to adipose tissue. Adiposity impacts physiological and mechanical variables which contribute to increased risk of postoperative complication. Importantly, these variables may represent more reliable prognostic factors compared to the anthropometric description provided by BMI.

There are noted positions in favor of and against adiposity being a reliable predictor for complication following THA. Sprowles et al.²⁶ reported that the median BMI was only 3.3 kg/m² greater in patients with deep infection compared to those without deep infection. Conversely, the median soft tissue thickness was 26.5 mm greater in patients with deep infection compared to those who did not develop this complication. These findings indicate that radiographic adiposity at the hip may be a more “clinically obvious” metric which requires further investigation in THA cases. Bell et al.²⁴ postulated on the reasons for adiposity not being predictive for wound complications following THA. The incision for THA follows a trajectory that is parallel to Langer's lines, whereas a TKA incision crosses these lines. Further, the THA incision is under a high degree of tension during postoperative rehabilitation compared to the knee which functions across a wider arc of motion. This display of conflicting evidence is indicative of an unsolved problem. There is a need for uniformity in case definitions and measurement criteria which will yield a higher level of evidence. Risk stratification in obese patients should utilize easily attainable metrices which provide reliable and accurate assessment. Continued investigation will determine whether adiposity performs according to these criteria.

Limitations of the current work include those that are inherent to the methodology of literature reviews. Namely, the study parameters and case definitions of the reviewed articles. These factors prevented an aggregate quantified result. However, the descriptive nature of the work contributes to further understanding of adiposity as a proxy for obesity which is an emerging concept. There are important economic and medical implications to stratifying risk for complications following primary THA. The metric that serves as a proxy for obesity should be easily attainable and should be reproducible and reliable for the intended application.

5 Conclusion

The use of BMI as a predictor for postoperative complication has been fraught with inconsistency. There is momentum for adiposity to be used as a proxy for obesity in primary THA risk stratification. Across six articles and 2931 cases, our findings demonstrated that local adiposity may be a reliable predictor for complications following primary THA.

Funding/Sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Informed consent

Not applicable.

Institutional ethical committee approval

Not applicable.

Author contribution

JJH: conceptualization, methodology, formal analysis, investigation, resources, data curation, writing - original, review & editing, visualization, project administration. YMF: formal analysis, investigation, resources, data curation, writing - review & editing. PAS: formal analysis, investigation, resources, data curation, writing - review & editing. AC: conceptualization, methodology, writing - review & editing, supervision, project administration.

References

Learmonth I.D., Young C., Rorabeck C., . The operation of the century: total hip replacement. Lancet. 2007;370(9597):1508-1519.
[Google Scholar]
Varacallo M., Chakravarty R., Denehy K., Star A., . Joint perception and patient perceived satisfaction after total hip and knee arthroplasty in the American population. J Orthop. 2018;15(2):495-499.
[Google Scholar]
Singh J.A., Yu S., Chen L., Cleveland J.D., . Rates of total joint replacement in the United States: future projections to 2020-2040 using the national inpatient sample. J Rheumatol. 2019;46(9):1134-1140.
[Google Scholar]
Kurtz S., Ong K., Lau E., Mowat F., Halpern M., . Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780-785.
[Google Scholar]
Heo S.M., Harris I., Naylor J., Lewin A.M., . Complications to 6 months following total hip or knee arthroplasty: observations from an Australian clinical outcomes registry. BMC Muscoskel Disord. 2020;21(1):602.
[Google Scholar]
DeMik D.E., Carender C.N., Glass N.A., Brown T.S., Elkins J.M., Bedard N.A., . Not all total hip and knee arthroplasties are the same: what are the implications in large database studies? J Arthroplasty. 2022;37(7):1247-1252.
[Google Scholar]
Kurtz S.M., Lau E.C., Son M.S., Chang E.T., Zimmerli W., Parvizi J., . Are we winning or losing the battle with periprosthetic joint infection: trends in periprosthetic joint infection and mortality risk for the medicare population. J Arthroplasty. 2018;33(10):3238-3245.
[Google Scholar]
Premkumar A., Kolin D.A., Farley K.X., et al . Projected economic burden of periprosthetic joint infection of the hip and knee in the United States. J Arthroplasty. 2021;36(5):1484-1489.
[Google Scholar]
Carender C.N., Glass N.A., DeMik D.E., Elkins J.M., Brown T.S., Bedard N.A., . Projected prevalence of obesity in primary total hip arthroplasty: how big will the problem get? J Arthroplasty. 2022;37(5):874-879.
[Google Scholar]
Gutin I., . In BMI we trust: reframing the body mass index as a measure of health. Soc Theor Health. 2018;16(3):256-271.
[Google Scholar]
McLaughlin J., Elsey J., Kipping R., Owen-Smith A., Judge A., McLeod H., . Access to hip and knee arthroplasty in England: commissioners' policies for body mass index and smoking status and implications for integrated care systems. BMC Health Serv Res. 2023;23(1):77.
[Google Scholar]
Richardson G., Dusik C., Lethbridge L., Dunbar M., . Variable effects of obesity on access to total hip and knee arthroplasty. Can J Surg. 2021;64(1):E84-e90.
[Google Scholar]
Eto K., Ida S., Ohashi T., et al . Perirenal fat thickness as a predictor of postoperative complications after laparoscopic distal gastrectomy for gastric cancer. BJS Open. 2020;4(5):865-872.
[Google Scholar]
Donnally C.J., Henstenburg J.M., Pezzulo J.D., et al . Increased surgical site subcutaneous fat thickness is associated with infection after posterior cervical fusion. Surg Infect. 2022;23(4):364-371.
[Google Scholar]
Kozlow J.H., Lisiecki J., Terjimanian M.N., et al . Cross-sectional area of the abdomen predicts complication incidence in patients undergoing sternal reconstruction. J Surg Res. 2014;192(2):670-677.
[Google Scholar]
Fujii T., Tsutsumi S., Matsumoto A., et al . Thickness of subcutaneous fat as a strong risk factor for wound infections in elective colorectal surgery: impact of prediction using preoperative CT. Dig Surg. 2010;27(4):331-335.
[Google Scholar]
Frenkel Rutenberg T., Markman R., Rutenberg R., Daglan E., Rubin T., Shemesh S., . Thickness of the subcutaneous fat as a risk factor for surgical site infection following fragility hip fracture surgery. Geriatr Orthop Surg Rehabil. 2022;13
[Google Scholar]
Ledford C.K., Millikan P.D., Nickel B.T., et al . Percent body fat is more predictive of function after total joint arthroplasty than body mass index. J Bone Joint Surg Am. 2016;98(10):849-857.
[Google Scholar]
Waisbren E., Rosen H., Bader A.M., Lipsitz S.R., Rogers S.O., Eriksson E., . Percent body fat and prediction of surgical site infection. J Am Coll Surg. 2010;210(4):381-389.
[Google Scholar]
Sterne J.A., Hernán M.A., Reeves B.C., et al . ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.
[Google Scholar]
Huguet A., Hayden J.A., Stinson J., et al . Judging the quality of evidence in reviews of prognostic factor research: adapting the GRADE framework. Syst Rev. 2013;2:71.
[Google Scholar]
Sprowls G.R., Allen B.C., Lundquist K.F., Sager L.N., Barnett C.D., . Incision site fat thickness and 90-day complications for direct anterior and posterior approach total hip arthroplasty. Hip Int. 2022;32(4):431-437.
[Google Scholar]
Mayne A.I.W., Cassidy R.S., Magill P., Diamond O.J., Beverland D.E., . Increased fat depth is not associated with increased risk of surgical complications following total hip arthroplasty. Bone Joint Lett J. 2020;102-b(9):1146-1150.
[Google Scholar]
Bell J.A., Jeong A., Bohl D.D., Levine B., Della Valle C., Nam D., . Does peritrochanteric fat thickness increase the risk of early reoperation for infection or wound complications following total hip arthroplasty? J Orthop. 2019;16(5):359-362.
[Google Scholar]
Rey Fernández L., Angles Crespo F., Miguela Álvarez S.M., Bernaus-Johnson M.C., Bartra Ylla A., Font-Vizcarra L., . Soft-tissue thickness radiographic measurement: a marker to evaluate acute periprosthetic joint infection risk in total hip replacement. J Bone Jt Infect. 2021;6(6):211-217.
[Google Scholar]
Sprowls G.R., Allen B.C., Wilson T.J., Pruszynski J.E., Hammonds K.A.P., . Predictive value of lateral soft tissue thickness for complications after total hip arthroplasty with a lateral incision. Proc (Bayl Univ Med Cent). 2020;33(3):336-341.
[Google Scholar]
Sezgin E.A., Ali A.K., Ataoğlu M.B., Orhan Ö., Odluyurt M., Esen E., . Novel radiographic hip fat thickness ratio correlates with early re-operation following total hip arthroplasty. Hip Int. 2022;32(1):62-66.
[Google Scholar]
Lash H., Hooper G., Hooper N., Frampton C., . Should a patients BMI status be used to restrict access to total hip and knee arthroplasty? Functional outcomes of arthroplasty relative to BMI - single centre retrospective review. Open Orthop J. 2013;7:594-599.
[Google Scholar]
Davis W., Porteous M., . Joint replacement in the overweight patient: a logical approach or new form of rationing? Ann R Coll Surg Engl. 2007;89(3):203-206.
[Google Scholar]
Giori N.J., Amanatullah D.F., Gupta S., Bowe T., Harris A.H.S., . Risk reduction compared with access to care: quantifying the trade-off of enforcing a body mass index eligibility criterion for joint replacement. J Bone Joint Surg Am. 2018;100(7):539-545.
[Google Scholar]