The impact of childhood obesity on orthopaedic practices is increasing as this unhealthy epidemic spreads. Traditionally, an orthopaedic surgeon treating an obese child was most concerned about the common associated musculoskeletal disorders such as Blount disease and slipped capital femoral epiphysis (SCFE). But today, orthopaedists must consider other significant health problems as well.
During the 2011 annual conference of the American Academy of Pediatrics (AAP), an entire symposium, sponsored by the AAP Section on Orthopaedics, was devoted to “Childhood Obesity and Its Effects on the Growing Skeleton.” Organized by AAOS member Todd A. Milbrandt, MD, and AAP member Blaise Nemeth, MD, the symposium covered a range of issues ranging from the general health status of obese children to specific conditions and treatment.
“I think that anybody who is in the obese category by BMI [body mass index] probably needs to be screened for sleep apnea, hypertension, and diabetes at the least,” said Dr. Milbrandt, a pediatric orthopaedic surgeon who practices at the Shriner’s Hospital in Lexington, Ky. He shared some alarming findings he discovered when he reviewed the health status of his obese patients.
Dr. Milbrandt’s group examined the blood pressures of patients diagnosed with Blount disease who were scheduled for elective surgery. Rather unexpectedly, they discovered a high prevalence of hypertension.
“Blood pressure was in the normal range in only 18 percent of the patients,” he reported. “Nearly 25 percent were stage II hypertensive, the highest stage possible.”
Dr. Milbrandt noted that many patients required medical therapy to treat the hypertension before they could be cleared for surgery. He now recommends that orthopaedists routinely check the blood pressures of obese patients prior to scheduling surgery—something that may not currently be standard practice.
The study also demonstrated a direct correlation between the patient’s BMI and blood pressure measurements. “There is a direct correlation between higher BMI and higher blood pressure,” he said. The study’s findings were consistent across all age groups, including half of the patients with infantile Blount disease. Dr. Milbrandt recommends that all orthopaedists measure the BMI of at-risk patients and emphasizes the importance of using age-adjusted tables to calculate the percentiles.
Obesity and perioperative complications
Obesity also has an impact on the rates of perioperative complications. Dr. Milbrandt presented his data on complication rates following scoliosis surgery in adolescent girls. “Overweight and obese patients had a 70 percent complication rate,” he said. The most common complication was persistent wound drainage. Heavier girls also had significantly longer surgical times and hospital stays.
These findings have altered his postoperative protocol. “Now, overweight and obese female scoliosis patients receive perioperative oral antibiotics and those who have persistent wound drainage are seen every week until the draining stops. Our wound closure protocol has also changed; we now use wound glue with large, long butterfly stitches in addition to a subcuticular closure. This seems to decrease the postoperative drainage,” he added.
Sean Barnett, MD, MS, a pediatric surgeon specializing in bariatric surgery at Cincinnati Children’s Hospital Medical Center, provided an update on the surgical treatment of obesity. His data illustrated the rising prevalence of childhood obesity in America.
“About 18 percent of youths and adolescents across the country are considered obese, defined as a BMI greater than 30,” said Dr. Barnett. Data show that 50 percent to 77 percent of obese children will remain obese into adulthood. The 2 million children in America who are considered morbidly obese—defined as having a BMI greater than 40—have a dismal prognosis without treatment.
“According to the literature, 100 percent of children with a BMI of 40 or greater will be morbidly obese as adults,” he added.
Dr. Barnett summarized the indications for obesity surgery. “In the past, we generally did not operate on kids until their BMI was 50, but that has changed significantly over the last decade,” he said. Today, morbidly obese adolescents who are sexually mature and have a BMI of 40 or greater are considered possible candidates for bariatric or gastric bypass surgery.
The current recommendations extend surgical treatment to severely obese adolescents with a BMI greater than 35 and significant comorbidities such as Type 2 diabetes mellitus, moderate to severe obstructive sleep apnea, severe steatohepatitis (fatty liver), or pseudotumor cerebri.
Pseudotumor cerebri is of particular concern due to the long-term ramifications. “Children with pseudotumor cerebri can go blind and will not recover their sight,” explained Dr. Barnett. “With bariatric surgery, they lose weight and the progression of the blindness stops. Although they will not regain any sight loss, losing weight stops the progression.”
Other related conditions
According to Dr. Nemeth, a pediatrician in the pediatric orthopaedic unit at the University of Wisconsin at Madison, orthopaedists may be able to diagnose Developmental Coordination Disorder (DCD) in some of their obese patients. Obese children have a high incidence of DCD.
“These kids have a much higher rate of weight gain compared to their normal peers,” said Dr. Nemeth, who considers the diagnosis when parents describe their overweight or obese child who “runs funny.” He explained that DCD impairs the child’s ability to exercise, resulting in more weight gain.
A developmental pediatrician frequently makes the diagnosis of DCD, so the challenge for orthopaedists is to identify patients who should be referred for evaluation.
“I begin to suspect DCD when the child has a history of trouble keeping up with his or her peers,” said Dr. Nemeth. “I also ask how old was the child when he or she started riding a bike without training wheels. Normally, 4- to 5-year-olds are able to do this. If the child is 7 or 8 and can’t ride a two-wheeler, I think that suggests a problem with balance, coordination, and vestibulomotor function.”
Dr. Nemeth prescribes both physical and occupational therapy for patients with DCD and plans to study his results more scientifically. “Because some children have maintained or lost weight with therapy, I think a prospective study is needed to see what happens to their weight control,” he said.
Foot pain in the obese child is another frequently encountered symptom. Dr. Nemeth said that several of his obese patients have a rigid idiopathic flat foot, previously described by Perry Schoenecker, MD, and Scott J. Luhmann, MD. Dr. Nemeth said this group has “a rigid foot that is negative for any type of coalition or other cause.”
The exact pathogenesis is not known, but the condition may be a late sequela of obesity and pressure on the foot, resulting in midfoot breach and a tight Achilles tendon. Early identification is needed to avoid surgery. Dr. Nemeth uses an Achilles tendon stretching program, orthotics, and weight reduction to try to alleviate the symptoms.
Diet and exercise
Restricting caloric intake and increasing energy consumption through exercise are critical components of any weight loss program. Many orthopaedists incorrectly assume that treatment of a painful condition such as a SCFE or Blount disease will facilitate weight loss for patients. Dr. Milbrandt’s patients, however, continued to gain weight after surgical treatment for these conditions.
“No matter what we do, they are still gaining weight,” he said. These findings may help explain the increased need for bariatric surgery in severely obese adolescents.
Unfortunately, simply identifying and referring severely obese children for treatment may not solve the problem. “In published studies, one third to one half of severely obese children do not even complete nonsurgical weight loss programs,” said Dr. Barnett. “Those who do only drop about five pounds and do not maintain the weight loss. It is really hard for morbidly obese children to lose weight nonsurgically.”
Despite these challenges, some orthopaedic surgeons have started addressing the obesity epidemic in their practices.
“I give the parents of all my obese patients a form that documents the child’s BMI,” said Joseph J. Gugenheim, MD, a pediatric orthopaedist and a member of The Obesity Society, an organization dedicated to advancing the scientific understanding of the causes, consequences, prevention, and treatment of obesity. He also sends a report of the child’s BMI to the patient’s primary care physician. “I try to emphasize that they are dealing with a long-term problem.”
Howard R. Epps, MD, is a pediatric orthopaedic surgeon and a member of the AAOS Now Editorial Board. He recently led a roundtable discussion on perioperative issues associated with treating obese children (AAOS Now, December 2011).