case study for surgery

• Search Menu
• Sign in through your institution
• Volume 2024, Issue 6, June 2024 (In Progress)
• Volume 2024, Issue 5, May 2024
• Bariatric Surgery
• Breast Surgery
• Cardiothoracic Surgery
• Colorectal Surgery
• Colorectal Surgery, Upper GI Surgery
• Gynaecology
• Hepatobiliary Surgery
• Interventional Radiology
• Neurosurgery
• Ophthalmology
• Oral and Maxillofacial Surgery
• Otorhinolaryngology - Head & Neck Surgery
• Paediatric Surgery
• Plastic Surgery
• Transplant Surgery
• Trauma & Orthopaedic Surgery
• Upper GI Surgery
• Vascular Surgery
• Author Guidelines
• Submission Site
• Open Access
• Reasons to Submit
• About Journal of Surgical Case Reports
• Editorial Board
• Advertising and Corporate Services
• Journals Career Network
• Self-Archiving Policy
• Journals on Oxford Academic
• Books on Oxford Academic

Senior Editors

Mr Julien Al Shakarchi

Mr Tariq Ali

Mr Varun Dewan

Mr Khalid Hussain

Case Report of the Year

Reveal the latest Case Report of the Year, as selected by our expert panel, to inform your research and practice.

Latest articles

Browse by specialty

JSCR publishes surgical techniques, case reports, and series across all surgical specialties. Browse collections including orthopaedics , vascular surgery , and urology .

Explore more

‘ A rare case of inflammatory breast cancer with delayed auto-amputation in modern times ’ has been selected as this years' winning case report, following a review by our expert panel.

Read the winning case report now

Benefits of publishing with  JSCR

Time from submission to first decision: 21 days Article Processing Charges (APC):

• Case Report/Surgical Technique $849
• Case Series $970

Email alerts

Register to receive table of contents email alerts as soon as new issues of  Journal of Surgical Case Reports  are published online.

Register now

Why submit to JSCR ?

JSCR publishes original surgical techniques, case reports, and series that expand the field of surgery. Discover our top reasons why you should submit your manuscript.

• Find out more
• Submit your case

Enhanced discoverability

JSCR deposits all cases in PubMed Central . Surgeons, physicians, dentists and researchers can find your work through PubMed , helping you reach the widest possible audience.

The journal is also indexed in the Web of Science Core Collection .

Related Titles

Affiliations

• Online ISSN 2042-8812
• Copyright © 2024 Oxford University Press and JSCR Publishing Ltd
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

Recent Search Keywords

• Surgical Case Reports

Review Time

Publish time, about journal scr.

Surgical Case Reports (SCR) the renowned official journal. Dive into a comprehensive collection of gastroenterological surgery, cardiovascular surgery, thoracic surgery, and more. Our open-access platform, supported by rigorous peer-review processes, showcases novel treatments and unique surgical experiences from around the globe.

The journal aims to develop and uphold the highest research standards, to provide a scope for evidence-based treatments through the publication of quick review papers and special issues, and to contextualise the findings through the publication of editorials, commentaries, and letters from the surgical community. We enforce reporting guidelines and require that all research involving human participants be registered in a public access research database.

From transplant surgery insights to rare breast and endocrine surgery tales, SCR is committed to advancing the realm of surgical science. By encapsulating unique cases and innovative treatments, we aim to foster a rich educational forum for clinicians and researchers alike.  

Scope of Journal

Surgical Case Reports (SCR) is a dedicated platform aiming to advance the understanding and practice of surgery. Our principal goal is to provide a global forum where clinicians, surgeons, and researchers can share, learn, and discuss novel surgical techniques, treatments, and patient case studies that contribute to the field's progress.

Submit Manuscript

For submission authors can directly submit manuscript to [email protected] . If you want to proceed with online submission you can follow the below link. You will need to be a register user to submit your manuscript.

Submit Online

General Information

Manuscripts number will be provided to the corresponding author within 72 hours for the respective manuscript submitted.

• • 14 days review process with international peer-review standards
• • Timeline of processing from Submission to Publication is 30 days
• • Manuscript will be published within 7 days of acceptance

Open Access

All the work at Surgical Case Reports is licensed under a Creative Commons Attribution 4.0 International License. Authors at Surgical Case Reports retain copyright to their work and allow others to copy, distribute, transmit, and adapt their work, provided proper attribution is given.

We follow Creative Commons 'Attribution' licence (CC BY) . This license lets others distribute, remix, tweak, and build upon your work, even commercially, as long as they credit you for the original creation. View License Deed | View Legal Code

Indexing and Abstract

All articles are made open access to maximise the long-term visibility, impact and influence of our content.

• • AcademicPub
• • The British Library
• • Cancerlit
• • Google Scholar
• • Medline/PubMed
• • Science Citation Index Expanded
• • Scisearch
• • Web of Science
• • Emerging Sources Science Citation Index

About Journal

Peer review process, editorial board, article processing charge, article in press, current issue.

Peer Review

Highest quality of international peer review standard

Initial submission.

Select the right journal and submit your manuscript.

Manuscript Number

Our editors will communicate and send you the manuscript number. We officially begin processing your manuscript.

First Decision

Based on the outcome of the peer-review you would receive review comments from the international experts on your subject.

APC Invoicing

We will share the invoice that can be paid online using credit card or bank transfer. We also have option to convert the invoice in the desired currency.

Proofing & Correction

Once you are aware of the review comments then you can make minor changes based on the inputs and any corrections that should be done before we move ahead.

Indexing & Archiving

If your research is not easy to find, it cannot help advance science or scientific society. Post-publication of your research, indexing is the most important things we do at Surgical Case Reports. We aim to make all articles published with Surgical Case Reports easy to find by the widest audience and also work with search engines, social media platforms and scholarly communication networks.

Case Reports

Preparing your manuscript.

The title page should:

• "A versus B in the treatment of C: a randomized controlled trial", "X is a risk factor for Y: a case control study", "What is the impact of factor X on subject Y: A systematic review, A case report etc."
• or, for non-clinical or non-research studies: a description of what the article reports
• if a collaboration group should be listed as an author, please list the Group name as an author. If you would like the names of the individual members of the Group to be searchable through their individual PubMed records, please include this information in the “Acknowledgements” section in accordance with the instructions below
• indicate the corresponding author

The abstract should not exceed 350 words. Please minimize the use of abbreviations and do not cite references in the abstract. The abstract must include the following separate sections:

• Background: why the case should be reported and its novelty
• Case presentation: a brief description of the patient’s clinical and demographic details, the diagnosis, any interventions and the outcomes
• Conclusions: a brief summary of the clinical impact or potential implications of the case report

Three to ten keywords representing the main content of the article.

The Background section should explain the background to the case report or study, its aims, a summary of the existing literature.

Case presentation

This section should include a description of the patient’s relevant demographic details, medical history, symptoms and signs, treatment or intervention, outcomes and any other significant details.

Discussion (optional)

Author may add this section to discuss the implications of the outcomes from the case, any practical issues involved or any other issues not covered in other sections.

Conclusions

This should state clearly the main conclusions and include an explanation of their relevance or importance to the field.

Declarations

List of abbreviations

If abbreviations are used in the text they should be defined in the text at first use, and a list of abbreviations should be provided.

Ethics approval and consent to participate

Manuscripts reporting studies involving human participants, human data or human tissue must:

• include a statement on ethics approval and consent (even where the need for approval was waived)
• include the name of the ethics committee that approved the study and the committee’s reference number if appropriate

Studies involving animals must include a statement on ethics approval.

See our editorial policies for more information.

If your manuscript does not report on or involve the use of any animal or human data or tissue, this section is not applicable to your submission. Please state “Not applicable” in this section.

Consent for publication

If your manuscript contains any individual person’s data in any form, consent to publish must be obtained from that person, or in the case of children, their parent or legal guardian. All presentations of case reports must have consent to publish.

If your manuscript does not contain any individual persons data, please state “Not applicable” in this section.

Availability of data and materials

For all journals, SpringerOpen strongly encourages all datasets on which the conclusions of the manuscript rely to be either deposited in publicly available repositories (where available and appropriate) or presented in the main paper or additional supporting files, in machine-readable format (such as spreadsheets rather than PDFs) whenever possible. Please see the list of recommended repositories in our editorial policies.

For some journals, deposition of the data on which the conclusions of the manuscript rely is an absolute requirement. Please check the Criteria section for this article type (located at the top of this page) for journal specific policies.

For all journals, authors must include an “Availability of data and materials” section in their article detailing where the data supporting their findings can be found. If you do not wish to share your data, please state that data will not be shared, and state the reason.

For instructions on how to cite your data and format this section see preparation/style and formatting.

Competing interests

All financial and non-financial competing interests must be declared in this section. A competing interests form is available here . All authors of the manuscript should compete this form and return it to the corresponding author, who should upload these to the submission system along with the main manuscript.

See our editorial policies for a full explanation of competing interests. If you are unsure whether you or any of your co-authors have a competing interest please contact the editorial office.

All sources of funding for the research reported should be declared. The role of the funding body in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript should be declared.

Authors' contributions

The individual contributions of authors to the manuscript should be specified in this section.

Acknowledgements

Please acknowledge anyone who contributed towards the article who does not meet the criteria for authorship including anyone who provided professional writing services or materials.

Authors should obtain permission to acknowledge from all those mentioned in the Acknowledgements section.

See our editorial policies for a full explanation of acknowledgements and authorship criteria.

Group authorship: if you would like the names of the individual members of a collaboration Group to be searchable through their individual PubMed records, please ensure that the title of the collaboration Group is included on the title page and in the submission system and also include collaborating author names as the last paragraph of the “Acknowledgements” section. Please add authors in the format First Name, Middle initial(s) (optional), Last Name. You can add institution or country information for each author if you wish, but this should be consistent across all authors.

Please note that individual names may not be present in the PubMed record at the time a published article is initially included in PubMed as it takes PubMed additional time to code this information.

Authors' information

You may choose to use this section to include any relevant information about the author(s) that may aid the reader's interpretation of the article, and understand the standpoint of the author(s). This may include details about the authors' qualifications, current positions they hold at institutions or societies, or any other relevant background information. Please refer to authors using their initials. Note this section should not be used to describe any competing interests.

Endnotes should be designated within the text using a superscript lowercase letter and all notes (along with their corresponding letter) should be included in the Endnotes section. Please format this section in a paragraph rather than a list.

Examples of the Vancouver reference style are shown below. 

See our editorial policies for author guidance on good citation practice.

Web links and URLs: All web links and URLs, including links to the authors' own websites, should be given a reference number and included in the reference list rather than within the text of the manuscript. They should be provided in full, including both the title of the site and the URL, as well as the date the site was accessed, in the following format: The Mouse Tumor Biology Database. http://tumor.informatics.jax.org/mtbwi/index.do . Accessed 20 May 2013. If an author or group of authors can clearly be associated with a web link, such as for weblogs, then they should be included in the reference.

Example reference style:

Article within a journal

Smith JJ. The world of science. Am J Sci. 1999;36:234-5.

Article within a journal (no page numbers)

Rohrmann S, Overvad K, Bueno-de-Mesquita HB, Jakobsen MU, Egeberg R, Tjønneland A, et al. Meat consumption and mortality - results from the European Prospective Investigation into Cancer and Nutrition. BMC Medicine. 2013;11:63.

Article within a journal by DOI

Slifka MK, Whitton JL. Clinical implications of dysregulated cytokine production. Dig J Mol Med. 2000; doi:10.1007/s801090000086.

Article within a journal supplement

Frumin AM, Nussbaum J, Esposito M. Functional asplenia: demonstration of splenic activity by bone marrow scan. Blood 1979;59 Suppl 1:26-32.

Book chapter, or an article within a book

Wyllie AH, Kerr JFR, Currie AR. Cell death: the significance of apoptosis. In: Bourne GH, Danielli JF, Jeon KW, editors. International review of cytology. London: Academic; 1980. p. 251-306.

OnlineFirst chapter in a series (without a volume designation but with a DOI)

Saito Y, Hyuga H. Rate equation approaches to amplification of enantiomeric excess and chiral symmetry breaking. Top Curr Chem. 2007. doi:10.1007/128_2006_108.

Complete book, authored

Blenkinsopp A, Paxton P. Symptoms in the pharmacy: a guide to the management of common illness. 3rd ed. Oxford: Blackwell Science; 1998.

Online document

Doe J. Title of subordinate document. In: The dictionary of substances and their effects. Royal Society of Chemistry. 1999. http://www.rsc.org/dose/title of subordinate document. Accessed 15 Jan 1999.

Online database

Healthwise Knowledgebase. US Pharmacopeia, Rockville. 1998. http://www.healthwise.org. Accessed 21 Sept 1998.

Supplementary material/private homepage

Doe J. Title of supplementary material. 2000. http://www.privatehomepage.com. Accessed 22 Feb 2000.

University site

Doe, J: Title of preprint. http://www.uni-heidelberg.de/mydata.html (1999). Accessed 25 Dec 1999.

Doe, J: Trivial HTTP, RFC2169. ftp://ftp.isi.edu/in-notes/rfc2169.txt (1999). Accessed 12 Nov 1999.

Organization site

ISSN International Centre: The ISSN register. http://www.issn.org (2006). Accessed 20 Feb 2007.

Dataset with persistent identifier

Zheng L-Y, Guo X-S, He B, Sun L-J, Peng Y, Dong S-S, et al. Genome data from sweet and grain sorghum (Sorghum bicolor). GigaScience Database. 2011. http://dx.doi.org/10.5524/100012 .

General formatting information

Manuscripts must be written in concise English. For help on scientific writing, or preparing your manuscript in English, please see Springer's  Author Academy .

Quick points:

• Use double line spacing
• Include line and page numbering
• Use SI units: Please ensure that all special characters used are embedded in the text, otherwise they will be lost during conversion to PDF
• Do not use page breaks in your manuscript

File formats

The following word processor file formats are acceptable for the main manuscript document:

• Microsoft word (DOC, DOCX)
• Rich text format (RTF)
• TeX/LaTeX 

Please note: editable files are required for processing in production. If your manuscript contains any non-editable files (such as PDFs) you will be required to re-submit an editable file if your manuscript is accepted.

For more information, see ' Preparing figures ' below.

Additional information for TeX/LaTeX users

You are encouraged to use the Springer Nature LaTeX template when preparing a submission. A PDF of your manuscript files will be compiled during submission using pdfLaTeX and TexLive 2021. All relevant editable source files must be uploaded during the submission process. Failing to submit these source files will cause unnecessary delays in the production process.  

Style and language

For editors and reviewers to accurately assess the work presented in your manuscript you need to ensure the English language is of sufficient quality to be understood. If you need help with writing in English you should consider:

• Getting a fast, free online grammar check .
• Visiting the English language tutorial which covers the common mistakes when writing in English.
• Asking a colleague who is proficient in English to review your manuscript for clarity.
• Using a professional language editing service where editors will improve the English to ensure that your meaning is clear and identify problems that require your review. Two such services are provided by our affiliates Nature Research Editing Service and American Journal Experts . SpringerOpen authors are entitled to a 10% discount on their first submission to either of these services. To claim 10% off English editing from Nature Research Editing Service, click here . To claim 10% off American Journal Experts, click here .

Please note that the use of a language editing service is not a requirement for publication in Surgical Case Reports and does not imply or guarantee that the article will be selected for peer review or accepted.  为便于编辑和评审专家准确评估您稿件中陈述的研究工作，您需要确保文稿英语语言质量足以令人理解。如果您需要英文写作方面的帮助，您可以考虑：

• 获取快速、免费的在线  语法检查 。
• 查看一些有关英语写作中常见语言错误的 教程 。
• 请一位以英语为母语的同事审阅您的稿件是否表意清晰。
• 使用专业语言编辑服务，编辑人员会对英语进行润色，以确保您的意思表达清晰，并提出需要您复核的问题。例如我们的附属机构 Nature Research Editing Service 以及合作伙伴 American Journal Experts 都可以提供此类专业服务。SpringerOpen作者享受首次订单10%优惠，该优惠同时适用于两家公司。您只需点击以下链接即可开始。使用 Nature Research Editing Service的编辑润色10%的优惠服务，请点击 这里 。使用 American Journal Experts的10%优惠服务，请点击 这里 。

请注意，使用语言编辑服务并非在期刊上发表文章的必要条件，这也并不意味或保证文章将被选中进行同行评议或被接受。 エディターと査読者があなたの論文を正しく評価するには、使用されている英語の質が十分であることが必要とされます。英語での論文執筆に際してサポートが必要な場合には、次のオプションがあります：

• 高速なオンライン  文法チェック  を無料で受ける。
• 英語で執筆する際のよくある間違いに関する 英語のチュートリアル を参照する。
• 英語を母国語とする同僚に、原稿内の英語が明確であるかをチェックしてもらう。
• プロの英文校正サービスを利用する。校正者が原稿の意味を明確にしたり、問題点を指摘し、英語を向上させます。 Nature Research Editing Service と American Journal Experts の2つは弊社と提携しているサービスです。SpringerOpenのジャーナルの著者は、いずれかのサービスを初めて利用する際に、10%の割引を受けることができます。Nature Research Editing Serviceの10%割引を受けるには、 こちらをクリックしてください 。. American Journal Expertsの10%割引を受けるには、 こちらをクリックしてください 。

英文校正サービスの利用は、このジャーナルに掲載されるための条件ではないこと、また論文審査や受理を保証するものではないことに留意してください。 영어 원고의 경우, 에디터 및 리뷰어들이 귀하의 원고에 실린 결과물을 정확하게 평가할 수 있도록, 그들이 충분히 이해할 수 있을 만한 수준으로 작성되어야 합니다. 만약 영작문과 관련하여 도움을 받기를 원하신다면 다음의 사항들을 고려하여 주십시오:

• 영어 튜토리얼 페이지 에 방문하여 영어로 글을 쓸 때 자주하는 실수들을 확인합니다.
• 귀하의 원고의 표현을 명확히 해줄 영어 원어민 동료를 찾아서 리뷰를 의뢰합니다
• 리뷰에 대비하여, 원고의 의미를 명확하게 해주고 리뷰에서 요구하는 문제점들을 식별해서 영문 수준을 향상시켜주는 전문 영문 교정 서비스를 이용합니다. Nature Research Editing Service 와 American Journal Experts 에서 저희와 협약을 통해 서비스를 제공하고 있습니다. SpringerOpen에서는 위의 두 가지의 서비스를 첫 논문 투고를 위해 사용하시는 경우, 10%의 할인을 제공하고 있습니다. Nature Research Editing Service이용시 10% 할인을 요청하기 위해서는 여기 를 클릭해 주시고, American Journal Experts 이용시 10% 할인을 요청하기 위해서는 여기 를 클릭해 주십시오.

영문 교정 서비스는 게재를 위한 요구사항은 아니며, 해당 서비스의 이용이 피어 리뷰에 논문이 선택되거나 게재가 수락되는 것을 의미하거나 보장하지 않습니다.

Data and materials

For all journals, SpringerOpen strongly encourages all datasets on which the conclusions of the manuscript rely to be either deposited in publicly available repositories (where available and appropriate) or presented in the main paper or additional supporting files, in machine-readable format (such as spread sheets rather than PDFs) whenever possible. Please see the list of recommended repositories in our editorial policies.

For some journals, deposition of the data on which the conclusions of the manuscript rely is an absolute requirement. Please check the Instructions for Authors for the relevant journal and article type for journal specific policies.

For all manuscripts, information about data availability should be detailed in an ‘Availability of data and materials’ section. For more information on the content of this section, please see the Declarations section of the relevant journal’s Instruction for Authors. For more information on SpringerOpen's policies on data availability, please see our editorial policies .

Formatting the 'Availability of data and materials' section of your manuscript

The following format for the 'Availability of data and materials section of your manuscript should be used:

"The dataset(s) supporting the conclusions of this article is(are) available in the [repository name] repository, [unique persistent identifier and hyperlink to dataset(s) in http:// format]."

The following format is required when data are included as additional files:

"The dataset(s) supporting the conclusions of this article is(are) included within the article (and its additional file(s))."

For databases, this section should state the web/ftp address at which the database is available and any restrictions to its use by non-academics.

For software, this section should include:

• Project name: e.g. My bioinformatics project
• Project home page: e.g. http://sourceforge.net/projects/mged
• Archived version: DOI or unique identifier of archived software or code in repository (e.g. enodo)
• Operating system(s): e.g. Platform independent
• Programming language: e.g. Java
• Other requirements: e.g. Java 1.3.1 or higher, Tomcat 4.0 or higher
• License: e.g. GNU GPL, FreeBSD etc.
• Any restrictions to use by non-academics: e.g. licence needed

Information on available repositories for other types of scientific data, including clinical data, can be found in our editorial policies .

What should be cited?

Only articles, clinical trial registration records and abstracts that have been published or are in press, or are available through public e-print/preprint servers, may be cited.

Unpublished abstracts, unpublished data and personal communications should not be included in the reference list, but may be included in the text and referred to as "unpublished observations" or "personal communications" giving the names of the involved researchers. Obtaining permission to quote personal communications and unpublished data from the cited colleagues is the responsibility of the author. Either footnotes or endnotes are permitted. Journal abbreviations follow Index Medicus/MEDLINE.

Any in press articles cited within the references and necessary for the reviewers' assessment of the manuscript should be made available if requested by the editorial office.

Preparing figures

When preparing figures, please follow the formatting instructions below.

• Figure titles (max 15 words) and legends (max 300 words) should be provided in the main manuscript, not in the graphic file.
• Tables should NOT be submitted as figures but should be included in the main manuscript file.
• Multi-panel figures (those with parts a, b, c, d etc.) should be submitted as a single composite file that contains all parts of the figure.
• Figures should be numbered in the order they are first mentioned in the text, and uploaded in this order.
• Figures should be uploaded in the correct orientation.
• Figure keys should be incorporated into the graphic, not into the legend of the figure.
• Each figure should be closely cropped to minimize the amount of white space surrounding the illustration. Cropping figures improves accuracy when placing the figure in combination with other elements when the accepted manuscript is prepared for publication on our site. For more information on individual figure file formats, see our detailed instructions.
• Individual figure files should not exceed 10 MB. If a suitable format is chosen, this file size is adequate for extremely high quality figures.
• Please note that it is the responsibility of the author(s) to obtain permission from the copyright holder to reproduce figures (or tables) that have previously been published elsewhere. In order for all figures to be open access, authors must have permission from the rights holder if they wish to include images that have been published elsewhere in non open access journals. Permission should be indicated in the figure legend, and the original source included in the reference list.

Figure file types

We accept the following file formats for figures:

• EPS (suitable for diagrams and/or images)
• PDF (suitable for diagrams and/or images)
• Microsoft Word (suitable for diagrams and/or images, figures must be a single page)
• PowerPoint (suitable for diagrams and/or images, figures must be a single page)
• TIFF (suitable for images)
• JPEG (suitable for photographic images, less suitable for graphical images)
• PNG (suitable for images)
• BMP (suitable for images)
• CDX (ChemDraw - suitable for molecular structures)

Figure size and resolution

Figures are resized during publication of the final full text and PDF versions to conform to the SpringerOpen standard dimensions, which are detailed below.

Figures on the web:

• width of 600 pixels (standard), 1200 pixels (high resolution).

Figures in the final PDF version:

• width of 85 mm for half page width figure
• width of 170 mm for full page width figure
• maximum height of 225 mm for figure and legend
• image resolution of approximately 300 dpi (dots per inch) at the final size

Figures should be designed such that all information, including text, is legible at these dimensions. All lines should be wider than 0.25 pt when constrained to standard figure widths. All fonts must be embedded.

Figure file compression

Vector figures should if possible be submitted as PDF files, which are usually more compact than EPS files.

• TIFF files should be saved with LZW compression, which is lossless (decreases file size without decreasing quality) in order to minimize upload time.
• JPEG files should be saved at maximum quality.
• Conversion of images between file types (especially lossy formats such as JPEG) should be kept to a minimum to avoid degradation of quality.

If you have any questions or are experiencing a problem with figures, please contact the customer service team at [email protected] .

Preparing tables

When preparing tables, please follow the formatting instructions below.

• Tables should be numbered and cited in the text in sequence using Arabic numerals (i.e. Table 1, Table 2 etc.).
• Tables less than one A4 or Letter page in length can be placed in the appropriate location within the manuscript.
• Tables larger than one A4 or Letter page in length can be placed at the end of the document text file. Please cite and indicate where the table should appear at the relevant location in the text file so that the table can be added in the correct place during production.
• Larger datasets, or tables too wide for A4 or Letter landscape page can be uploaded as additional files. Please see [below] for more information.
• Tabular data provided as additional files can be uploaded as an Excel spreadsheet (.xls ) or comma separated values (.csv). Please use the standard file extensions.
• Table titles (max 15 words) should be included above the table, and legends (max 300 words) should be included underneath the table.
• Tables should not be embedded as figures or spreadsheet files, but should be formatted using ‘Table object’ function in your word processing program.
• Color and shading may not be used. Parts of the table can be highlighted using superscript, numbering, lettering, symbols or bold text, the meaning of which should be explained in a table legend.
• Commas should not be used to indicate numerical values.

If you have any questions or are experiencing a problem with tables, please contact the customer service team at [email protected] .

Preparing additional files

As the length and quantity of data is not restricted for many article types, authors can provide datasets, tables, movies, or other information as additional files.

All Additional files will be published along with the accepted article. Do not include files such as patient consent forms, certificates of language editing, or revised versions of the main manuscript document with tracked changes. Such files, if requested, should be sent by email to the journal’s editorial email address, quoting the manuscript reference number.

Results that would otherwise be indicated as "data not shown" should be included as additional files. Since many web links and URLs rapidly become broken, SpringerOpen requires that supporting data are included as additional files, or deposited in a recognized repository. Please do not link to data on a personal/departmental website. Do not include any individual participant details. The maximum file size for additional files is 20 MB each, and files will be virus-scanned on submission. Each additional file should be cited in sequence within the main body of text.

Submit manuscript

• Editorial Board
• Sign up for article alerts and news from this journal

Affiliated with

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• BMC Cardiovasc Disord

Case report: Diagnosis and emergency surgery on a young patient with extensive aortic dissection without any risk factors

Masoud shafiee.

1 Department of Cardiac Surgery, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran

Mohsen Shafiee

2 Department of Nursing, Abadan University of Medical Sciences, Abadan, Iran

Noorollah Tahery

Omid azadbakht.

3 Radiology Technology Department, Behbahan Faculty of Medical Sciences, Behbahan, Iran

Zeinab Nassari

Reza baghbani.

4 Department of Medical Emergency, School of Allied Medical Sciences, Bushehr University of Medical Sciences, Bushehr, Iran

Associated Data

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Not applicable.

Type A aortic dissection is a very dangerous, fatal, and emergency condition for surgery. Acute aortic dissection is a rare condition, such that many patients will not survive without reconstructive surgery.

Case presentation

We present a case 24-year-old male who came with symptoms of shortness of breath and cough. The patient underwent ECG, chest radiology, and ultrasound, where the patient was found to have right pleural effusion while his ECG was normal. In the history taken from the patient, he had no underlying disease, no history of heart diseases in his family. For a better diagnosis, ETT and aortic CT angiography was performed on the patient which confirmed the evidence of dissection. Immediately after the diagnosis, necessary arrangements were made for open heart surgery and the patient was prepared for surgery. The patient was admitted in the cardiac surgery ICU for 5 days and his medication was carefully administered. After the conditions were stabilized, the patient was transferred to the post-cardiac surgery ICU ward. The patient was discharged from the hospital one week after the surgery and returned to the office as an OPD one week after his discharge.

Various risk factors can play a role in creating aortic dissection. Therefore, it is necessary to pay attention to patients’ history for achieving a quick and definitive diagnosis. Therefore, to control the complications of placing the cannula as well as the duration of the surgery, it is very important to reduce the duration of pumping on the patient and to be very careful during the cannula placement.

Type A aortic dissection is a very dangerous and fatal condition [ 1 ] and is an emergency indication for surgery, such that many patients will not survive without reconstructive surgery [ 2 ]. Acute aortic dissection is a rare condition with a prevalence of 3 to 4 individuals per 100,000. This condition is very serious since its mortality rate without surgery is 90%, while the mortality rate after surgery and hospitalization is 10–20% [ 3 ]. In general, there are many causes for aneurysms, including inherited, degenerative, atherosclerotic, inflammatory, and traumatic causes. Among these reasons, the most important factor is heredity [ 4 ]. The aorta has two models: model A, which mostly involves the aortic root, ascending aorta, and aortic arch, and the branches protruding from the aortic arch, and model B, which mostly involves the descending aorta [ 5 ]. The etiology of this disease in the thoracic aorta is changes in connective tissues, as well as mechanical, chemical, and genetic changes, but in the abdominal aorta, it is mostly due to inflammatory conditions. Genetics is responsible for 15% of the cases of this disease (Table  1 ). Hypertension (in two-thirds of patients due to stress on the vascular walls), Turner syndrome, Marfan syndrome, Ehlers-Danlos syndrome, and aortic inflammation (affected by the integrity of the vascular wall) are among the common causes of this disease. In any case, the incidence of symptoms such as chest pain, which starts suddenly [ 6 ] and spreads to the back, requires immediate treatment [ 2 ]. Many patients have suffered from chronic hypertension, nausea and severe anxiety, focal neurologic symptoms, coma, syncope (in 9% of cases), and pulse deficit. Other symptoms include cardiac tamponade with or without aortic rupture, pseudo-hypotension/peripheral hypotension with central norm tension, the murmur of aortic regurgitation, and acute myocardial infarction [ 6 ]. The cause of death in pre- and post-surgery conditions is impaired cardiac perfusion due to the nature of the disease [ 7 ]. Open-heart surgery is a well-known and common treatment for large aneurysms [ 8 ]. In this study, we reported a case that had no risk factors for aortic aneurysm. However, the delay in diagnosing the disease and the lack of treatment for this patient led to his death (Fig.  1 ).

Diagram of the process of diagnosis and treatment of the studied patient

Aortic dissection after sternotomy

The patient was a 24-year-old male who came with symptoms of shortness of breath and cough. The patient underwent ECG, chest radiology, and ultrasound and was found to have right pleural effusion while his ECG was normal. Early vital signs of the patient at the time of visiting the hospital were BP: 125/80, PR: 105, T: 37.4, RR: 32, SpO 2  = 96%. The history taken from the patient revealed that he had no underlying disease and no history of heart diseases in his family. Moreover, there was no history of inflammatory diseases in the patient or his family. The patient’s BMI was within the normal range, and he had a history of working in harsh conditions under high pressure. After admission, the patient underwent echocardiography ordered by a cardiologist, where according to the physician, evidence of aortic dissection was observed. For a better diagnosis, echocardiography through the esophagus was performed on the patient which confirmed the evidence of dissection. Since aortic dissection is a life-threatening emergency, an urgent aortic CT angiography was requested and performed as ordered by the patient’s physician, and aortic dissection of type A was confirmed in the patient. Immediately after the diagnosis, necessary arrangements were made for open-heart surgery and the patient was prepared for surgery. Blood samples were sent to a laboratory for the required tests (i.e., antibody, CBC, and similar tests), and to diagnose inflammatory processes and related syndromes tests such as RF, CRP, and IgG, among others, were used. The patient was immediately taken to the operating room for urgent surgery after obtaining informed consent from him and his family. It should be noted that blood samples were taken by professional nurses and sent to the laboratory under special conditions to reduce the error rate. To establish a cardiopulmonary pump for the patient, a number 19 canola was applied and the right femoral artery was used to cannulate the patient. After implanting a cannula in the femoral artery, the patient underwent sternotomy, his pericardium was opened, and his right atrium was cannulated. Then the patient went on the pump and his pump timing started. After performing sternotomy on the patient, we found that the dissection started from the aortic annulus and continued in the ascending aorta before the aortic arch. The size of the false lumen in the aneurysm was about 7–8 cm and led to severe aortic valve failure. After the start of the cardiopulmonary pump, the ascending aortic dissection was opened and imported into the right coronary artery and left main artery through a direct cannula and the patient received cardioplegia. The aortic annulus, ascending aorta, and aortic valve were completely removed. The composite graft with metal aortic valve was number 23 which was anastomosed to the aortic annulus, and the right coronary artery and left main artery were anastomosed to the composite graft. The distal composite was also anastomosed to the aortic arch. Three number 32 chest tubes were embedded in the mediastinum area and the right and left pleura. The patient had no arrhythmias during the surgery. The surgery lasted for about 6 h and the patient’s cardiopulmonary pumping took about 200 min. It should be noted that the patient received two units of blood during the surgery. After surgery, the patient was transferred to the cardiac surgery ICU with complete cardiac and respiratory monitoring and was placed under respiratory monitoring using a ventilator and a hemodynamic monitor upon arrival. The patient underwent intensive care in the cardiac surgery ICU and was constantly monitored for acute post-surgery side effects such as bleeding and cardiac tamponade. During the first 12 h of admission to the cardiac surgery ward, the patient’s mean arterial pressure was maintained between 65 and 70 mm Hg to prevent bleeding, and his systolic pressure was between 80 and 90 mm Hg. Moreover, due to the long duration of the surgery and the high possibility of bleeding, the patient was anesthetized for about 8 h using sedative drugs to ensure the post-surgery conditions. It is worth mentioning that during these 8 h, the patient’s pupils had normal reactions to light and were of normal size. The patient was constantly monitored. ABG was monitored and adjusted every hour. The patient’s electrolyte levels were also corrected. In the ward, the patient underwent chest radiography wherein no evidence of bleeding, tamponade, and pneumothorax was observed. The patient was hospitalized and remained under medical care in the cardiac surgery ICU for five days and his medication was carefully administered. After his conditions were stabilized, the patient was transferred to the post-cardiac surgery ICU ward. The patient was discharged from the hospital one week after the surgery and returned to the outpatient department (OPD) one week after his discharge. After visiting the OPD, the patient underwent CT angiography and echocardiography and his condition was stable. Moreover, his aortic valve, the ascending aorta, and right and left main coronaries worked well and the patient’s heart contraction was satisfactory with EF: 55% (Fig.  2 ).

Vental of Aortic dissection

In this study, we identified a case with aortic dissection that had no risk factors for this condition other than his gender. In this case, which, unlike other studies, had visited the hospital with respiratory symptoms, pleural effusion was reported [ 6 ]. On the other hand, no abnormal changes were observed in the patient’s EKG. In other words, the patient did not have any clear symptoms other than chest pain, which made the diagnosis of the disease by physicians considerably difficult. In this case, CT angiography was used for a definitive diagnosis. Some studies have suggested that bacteria such as C. septicum may play a role in the formation of aortic dissection [ 9 ]; however, there were no complaints regarding the existence of infectious symptoms by the patient and his WBC differential was normal. Genetics is involved in 15% of the cases of this disease. Common causes of this disease include hypertension (in two-thirds of the patients due to imposing stress on vascular walls), Turner syndrome, Marfan syndrome, Ehlers-Danlos syndrome, and aortic inflammation, which can affect the integrity of the vascular walls [ 2 ]. However, contrary to the results obtained from the literature, the patient did not suffer from any genetic disorders, hypertension, or any syndromes. The following are several other predictors of aortic dissection A: The prevalence of this disease is higher among men than women [ 5 ]; the prevalence of the disease increases with the increase of age; the risk of the disease increases with the increase of BMI; smoking and alcohol consumption increase the prevalence of the disease. On the other hand, in addition to factors such as sepsis, increased WBC, and INR changes, history of aneurysms can also be effective in causing an aneurysm. However, the studied patient had a normal BMI, along with normal laboratory results. Furthermore, the patient did not have a history of smoking and alcohol consumption and was young, and aortic dissection is rarely observed in this age group [ 10 ]. The only risk factors observed in this patient were his gender and working under harsh conditions. As stated in the literature, the prevalence of this disease is higher in men than women [ 5 ], and our case study was male; therefore, the existence of this disease in his body is justified. On the other hand, the results of the study by Aparci et al. suggested that environmental and occupational factors can affect aortic aneurysm; thus, this condition is considered an occupational disease. In addition, Aparci concluded that the nature of some occupations, such as sports occupations, heavy and stressful jobs, and military jobs, among others, affects the development of this disease [ 10 ]. The medical history of our case revealed that he had worked in very bad weather conditions, under high stress levels, and had carried heavy equipment, which were all occupational factors affecting this disease, consistent with the results of the study by Aparci. Moreover, aortic dissection has many side effects; one of these adverse effects is acute aortic valve failure, which appeared in our patient.

Type A aortic aneurysm is a dangerous and rare condition, which requires emergency medical treatment . Aortic dissection can lead to aortic valve failures, and thus requires immediate action to reduce the complications and mortality rate. Early diagnosis of this disease plays an essential role in its treatment . Various risk factors can play a role in the development of aortic dissection. These factors lead to various and atypical symptoms, which makes the disease difficult to diagnose. Therefore, it is necessary to pay attention to patients’ history to achieve a quick and definitive diagnosis. The most definitive method for diagnosing aortic dissection is CT angiography, and the best treatment for an acute aortic aneurysm is heart surgery. Moreover, the effects of gender and working conditions should not be neglected and must be further investigated.

Acknowledgements

Shiraz University of Medical Sciences and Abadan University of medical sciences.

Abbreviations

Authors' contributions.

MSH (1) visited the patient and performed the surgery. MSH (2), ZN, and RB provided pre- and post-operative nursing care. OA performed a CT angiography of the patient and reported the CT scan. MSH (1), NT, MSH (2), and OA contributed to the interpretation of the results. NT and MSH (2) took the lead in writing the manuscript. All authors provided critical feedback and helped shape the research, analysis and manuscript. All authors read and approved the final manuscript.

Availability of data and materials

Code availability, declarations.

The patient has provided medical information to the researchers with full consent. The patient filled out a consent form to participate in this study.

All participants included in this research gave written informed consent to publish the data contained within this study.

We declare that we have no significant competing financial, professional, or personal interests that might have influenced the performance or presentation of the work described in this manuscript. We have described us potential competing financial, professional, and/or personal interests in the space.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Masoud Shafiee, Email: moc.oohay@909meeifahS .

Mohsen Shafiee, Email: moc.oohay@smuyfki .

Noorollah Tahery, Email: moc.liamg@yrehattn .

Omid Azadbakht, Email: moc.liamg@86thkabdazadimo .

Zeinab Nassari, Email: moc.liamg@irasanbaniez .

Reza Baghbani, Email: [email protected] .

References:

• Search for:
• Dr. Nakul Karkare
• Dr. Thor Robert Rhodin
• Dr. Vedant Vaksha

Dr. Suhirad Khokhar

• Dr. Kevin Kuo
• Dr. Kenneth Alleyne
• Dr. Mo Athar
• Testimonials
• Patient Portal
• Workers Comp Hub
• Case Studies
• Forms & Downloads

Home » Case Studies » Knee » Case Study: Left Total Knee Replacement in a 62-year-old Male

Case Study: Left Total Knee Replacement in a 62-year-old Male

A 62-year-old male presented for evaluation of his left knee. Over the last seven months, he has had increasing knee pain and discomfort. He stated that in April he got up from a seated position and felt a “crack” within his knee.

He had earlier seen another physician who diagnosed him with a torn meniscus . He underwent a surgical arthroscopy, and following the procedure, his pain increased in severity. He saw another physician in August and was treated with a gel injection. He still had persistent pain and discomfort diffusely about his left knee joint.

He stated that he also gets some swelling in the back of the knee. The pain was sharp with weight-bearing and activities. He got a buckling sensation, clicking and limited range of motion. He described pain with transfers, his walking tolerance was less than a block. He used a cane as an assistive device.

He negotiated stairs one at a time with the use of the banister. He was on Percocet as well as Mobic. He also had a prior right total knee replacement a few years ago. He developed an infection three years after the procedure and underwent a two-staged revision with final reimplantation by an outside physician.

Currently, the right knee was minimally symptomatic, but he did develop a postoperative DVT (deep vein thrombosis) and pulmonary embolism requiring placement of an inferior vena cava filter three years ago. He had been on Coumadin therapy which was recently discontinued by her vascular surgeon. He had a history of low back pain and was going to pain management.

He was a retired school bus driver and currently lives with his wife. The patient was dismayed with the left knee pain and limited mobility secondary to pain. He was unable to do even basic tasks without pain and was apprehensive about climbing stairs. He was exploring the possibility of total knee replacement.

He was a past smoker having quit 30 years ago. Earlier he also had a trial of conservative management in the form of physical therapy and gel injections with minimal relief. He had a known drug allergy to Biaxin.

On his office visit, he was calm, conscious, cooperative and well oriented to time place and person. He walked with an antalgic gait with a reduced stance phase on the left side. The skin overlying the left skin demonstrated a well-healed scar suggestive of prior arthroscopic surgery.

There was mild swelling in the left knee. Pain and crepitus were present throughout the arch of motion. The range of movements was present from 10 degrees to 90 degrees. There was tenderness on the medial and lateral joint lines. Tenderness was also present on patellar facets.

There was mild genu varum deformity. There were no signs of instability or laxity in coronal, sagittal, and axial planes. The examination of the right knee revealed a well-healed anterior scar. The range of motion was full with no pain or stiffness.

The examination of the bilateral hip and ankle was normal. The neurological examination of the lower extremities was normal. The bulk and tone of both lower limbs were normal. The bilateral lower extremity pulses were palpable and comparable.

Imaging revealed severe tricompartmental osteoarthritis of the left knee with joint space reduction and osteophytes.

Considering the lifestyle limiting left knee pain, the patient was advised left knee total replacement. Risks, benefits, and alternatives were discussed with the patient at length. He agreed to undergo left total knee arthroplasty .

Anteroposterior and lateral view of the left knee

OPERATION: Left total knee replacement .

IMPLANTS USED: Posterior stabilized 8 left standard femoral component left-sided with tibia E left cemented with 14 x 30 stem with poly 16 mm with a 29-mm diameter poly patella.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room after obtaining informed consent, signing the correct surgical site. The risks, benefits, and alternatives were extensively discussed with the patient prior to the procedure.

The patient, as well as the family, understood that he had increased risk of complications including, but not limited to infection and deep vein thrombosis and pulmonary embolism.

Anesthesia was obtained by the anesthesiologist. The patient was then definitely positioned, and the left knee was then draped and prepped in the usual sterile manner. A straight incision centered over the patella was used for the arthrotomy.

Skin and subcutaneous tissues were then incised. A medial parapatellar arthrotomy was then performed. The knee was then exposed and the femoral cutting guide was then placed into position. The distal cut was then performed. The anterior, posterior, and then the chamfer cuts were then performed.

Attention was then turned towards the tibia. The tibial cut was then performed. Lamina spreaders were used medially and laterally, and the remainder of the meniscus was then debrided. The notch cut was then performed and the femur was then placed into position followed by the tibia.

The tibia was then broached and the trial poly was then placed into position. The gap balancing was performed before the final broaching and was found to be correct. The patella was then resected. The drill holes were made in the patella and then the trial patella was then placed into position.

The knee was then reduced. The knee was then ranged through a full range of motion and the patellar tracking was found to be normal, and the gap balancing was then again checked and was found to be satisfactory.

The trial components were then removed. Thorough lavage was given. The femur was cemented into position. Excess cement was then removed. The tibia was then cemented into position. Excess cement was then removed. Poly was then placed over the tibia. The knee was then reduced.

The knee was then held in full extension and then the patella was cemented into position and held in position with a patellar clamp. The excess cement was removed after the cement hardened. The knee was injected with intraarticular injection and thorough lavage was given.

Medial parapatellar arthrotomy was closed with Ethibond, cutaneous tissues were closed with 0 Vicryl, subcuticular tissues were closed with 2-0 Vicryl, and skin was closed using staples. Sterile dressing was then applied, and the patient was then transferred to the postoperative care unit in stable condition.

Postoperative X-ray of the left showing the anteroposterior and lateral view with total knee prosthesis in position.

The patient had an excellent recovery post-op , his pain was managed well with medications. He was started on Aspirin 325 mg BID for deep vein thrombosis prophylaxis. He was able to walk 100 feet on the same day of the procedure. He was discharged the following day.

The sutures were taken off 14th-day post-op with no complications. There was no swelling of the calves and no neurological deficit of the lower extremities. The patient underwent physical therapy to strengthen muscles and increase range of motion of the joint.

Three months post-op , the patient was able to walk with no pain and a full range of motion. He was extremely happy with the outcome of the procedure and was back to his baseline activities.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

Call Us Now!

(631) 981-2663.

On your phone? Tap here to text us!

• Knee Cartilage Damage
• Posterior Cruciate Ligament
• Post Operative Knee Arthroscopy
• Patellofemoral Pain
• Patellofemoral Instability
• Meniscal Tear of the Knee
• Anterior Cruciate Ligament
• Knee Bursitis
• Medial & Lateral Collateral Ligament of the Knee
• Unicompartmental Knee Replacement
• Meniscus Tear
• 3D Knee Implant

Knee Services

• Total Knee Replacement
• Custom Knee Replacement
• Cartilage Injury & Management
• KneeCap Maltracking and Management 
• High Tibial Osteotomy
• Subchondroplasty
• Total Knee Replacement Recovery Guide
• Cemented and Cementless Knee Replacement
• Knee Anatomy
• Achilles Tendon Injuries
• Revision Total Knee Replacement Surgery
• Cortisone Injection
• Knee Arthroplasty Implants
• Bilateral Knee Replacement (Simultaneous)
• Unstable Knee
• Knee Viscosupplementation
• Adjacent Segment Disease after Cervical Fusion
• Anterior Lumbar Interbody Fusion Surgery
• Cauda Equina Syndrome
• Hinged Knee Replacement
• Patient-Specific Knee Replacement – Customized Implants Vs Customized Cutting Blocks
• Iliotibial Band Syndrome
• Gender-Specific Knee Replacement
• Outpatient Knee Replacement
• Posterior Cruciate Ligament Injury
• Smart Total Knee Replacement for Healthcare Professionals
• Smart Total Knee Replacement

Knee Case Studies

• Left Total Knee Arthroplasty – 66 year old male
• Right Total Knee Arthroplasty – 51 year old male
• Custom Left Total Knee Replacement in a 66-year-old male
• Custom Total Knee Replacement in Left Knee Arthritis with prior Hardware on the Lateral Tibial Plateau
• Left Total Knee Replacement – 63 year old Female
• Case Study: Bilateral Custom Total Knee Replacement in a 72-year-old Male
• Customized Total Knee Replacement in a 59-year-old male
• Customized Total Knee Replacement in a 58-year-old female with Arthritis
• Left Custom Total Knee Arthroplasty in a 68-year-old male
• Custom Right Total Knee Arthroplasty – 62-year-old male
• Right Total Knee Replacement with Custom Instruments in a 67-year-old female
• Left Total Knee Replacement in a 68-year-old male
• Left Total Knee Replacement in a 62-year-old Male
• Right Total Knee Replacement in a 72-year-old female with Arthritis
• Right Total Knee Replacement with Custom Instruments in a 66-year-old male
• Right Custom Total Knee Replacement in a 68-year-old female
• Right Total Knee Replacement with Custom Instruments in a 60-year-old female with Avascular Necrosis of the Knee
• Left Custom Total Knee Replacement in a 74-year-old female
• Bilateral Customized Total Knee Replacement in a 72-year-old female
• Custom Right Total Knee Replacement in a 55-year-old Female with Prior ACL Reconstruction
• Bilateral Customized Total Knee Replacement in a 72-year-old patient with Arthritis
• Customized Left Total Knee Replacement in a 73-year-old Male
• Revision Total Knee Replacement in a 68-year-old male with prior Unicondylar Knee Replacement
• Bilateral Custom Total Knee Replacement in a 61-year-old male with Knee Arthritis & Genu Valgum Deformity
• Customized Left Knee Total Replacement in a 66-year-old female
• Customized Right Total Knee Replacement in a 73-year-old Male with Arthritis
• Custom Left Knee Total Replacement in a 68-year-old Female

My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.

• Español ( Spanish )

Musculoskeletal Key

Fastest musculoskeletal insight engine.

• MANUAL THERAPIST
• MUSCULOSKELETAL MEDICINE
• PHYSICAL MEDICINE & REHABILITATION
• RHEUMATOLOGY
• SPORT MEDICINE
• Gold Membership

Case studies in orthopaedics

CHAPTER SEVEN Case studies in orthopaedics Anne-Marie Hassenkamp, Diane Thomson, Sophia Mavraommatis, Kaye Walls Case study 1: Rotator Cuff Repair 166 Case study 2: Decompression/Discectomy 168 Case study 3: Fractured Neck of Femur 170 Case study 4: Total Knee Arthroplasty/Replacement 172 Case study 5: Anterior Cruciate Ligament Reconstruction 175 Case study 6: Fractured Tibia and Fibula 177 Case study 7: Achilles Tendon Repair 178 Case study 8: Idiopathic Scoliosis 180 Case study 9: Legg–Calvé–Perthes Disease 182 Case study 10: Surgical Intervention for Cerebral Palsy 185 Introduction Orthopaedics is a wide area of practice for physiotherapists and one which we encounter in most settings be it in a hospital (e.g. elective surgery, trauma or disease) or a community setting (e.g. post-operative, injury, secondary issues and long-term musculoskeletal problems). Due to the wide spectrum of orthopaedics the therapist is likely to encounter patients of all ages, from all backgrounds and with various health beliefs. Each one of these factors can have a huge influence on therapy management. Excellent communication and team working skills are essential. The orthopaedic physiotherapist is an integral member of the multidisciplinary team (MDT) and works closely with surgeons. The clinical reasoning and problem-solving approaches used are directed by the medical intervention. Clearly, a good knowledge of what is a normal change and what is a pathological one is of paramount importance. Higgs & Titchen (2000) remind us that knowledge is an essential element for reasoning and decision making, and how both of these are considered central to clinical practice. The therapist working in these settings has to have excellent anatomical, physiological and pathological background knowledge within a framework of an understanding of the psychosocial influences on rehabilitation goals. Atkinson (2005) advises the adoption of the long published movement continuum ( Cott et al 1995 ) as a good framework for orthopaedic reasoning. The changes from the person’s preferred movement capacity (PMC) to their current one (CMC) is the orthopaedic physiotherapist’s frame of reference. The process of getting from one to the other engages the therapist in educational as well as treatment situations which need the collaboration of the patient. Orthopaedic therapy goals therefore have to be patient-centred and collaborative rather than following a prescribed protocol. This makes orthopaedic physiotherapy an ideal training ground in reasoning for the starting professional. The hypothetico-deductive reasoning model ( Elstein et al 1978 ) adopted by junior physiotherapists is particularly well suited to this surgically directed arena as it stems from research in medical reasoning and hence mirrors that of the surgeon in charge of the patient. Pattern recognition ( Higgs & Jones 2000 ) – a sign of the more expert professional – allows for a quick integration into the clinical puzzle of many different pieces virtually simultaneously. Orthopaedic practice is an ideal setting for physiotherapists to become more aware of and more secure in their cognitive skills as well as honing them to expert level. CASE STUDY 1 Rotator cuff repair Subjective assessment PC 50-year-old female admitted for an arthroscopic left rotator cuff repair. The indications for surgery are: large rotator cuff tear demonstrated by MRI pain interfering with work as unable to use arm effectively above 90° night pain waking her 2–3 times per night failed course of conservative treatment including cortisone injection (twice) and physiotherapy over last 4/12 HPC Intermittent shoulder pain for about 18/12 Aggravated by reaching, particularly if sustained or repeated Patient felt excruciating pain while hanging curtains but worked through the pain for the rest of the day Was unable to sleep that night due to severe pain Attended A&E where X-ray showed no abnormality She was referred for physiotherapy which has now been ongoing for several months to no effect GP had given cortisone injections on two occasions which didn’t help Patient was then referred to an orthopaedic surgeon who organized an MRI and diagnosed a full thickness rotator cuff repair. She was listed for surgery SH Self-employed curtain maker. Has employed help for the time she will be off work Lives with husband Smoker Objective assessment Observation Increased thoracic kyphosis in relaxed standing/sitting but is able to actively correct this to a reasonable level Mild forward head posture and protracted shoulders which she can control Cervical and thoracic movements appear fine Pre-operative treatment aims Teach bed exercises for circulation Teach deep breathing exercises to maintain good chest expansion Explain post-operative management and introduce post-operative precautions. This is done with her husband present and it is explained that he will need to help with the exercises post operation Provide any written information sheets about post-operative care and discuss Post-operative treatment aims (for 0–6 week period) Monitor respiratory and circulatory status during immediate post-operative period Protect healing of soft tissues. Maximum protection phase Prevent negative effects of immobilization Monitor and assist in pain control Re-establish scapula stability Encourage good posture Arrange out patient/community physiotherapy as appropriate 1st day post-surgery Breathing exercises are checked looking for basal expansion and clearance of any sputum Patient is mobilised out of bed as soon as able wearing a blow-up abduction pillow She is taught: scapular setting exercises in side lying and sitting, scapula protraction/retraction for proprioception. Full range of neck movements passive external rotation to full range minus 20° for 3/52 in lying. Passive elevation to shoulder level for 3/52. Passive movements are preferably done by a family member or carer. This person will need to be taught this before patient is discharged that at 3/52 both elevation and external rotation can be encouraged into full passive range both in lying and in sitting. Aim for full passive range soon after 6/52 post operation ( Gibson 2007 ) good postural alignment using a mirror in sitting and standing After 6/52 Start weaning from the immobilisation device and use her arm for light use at waist level Increasing ROM in all directions including behind the back Isometric internal and external rotation in neutral can be started to strengthen the cuff Progression to resisted and anti-gravity exercises will be as stability and pain permit Correct postural positioning is important throughout Pain will be monitored and addressed by her GP if necessary Questions 1. What are the rotator cuff muscles and what is their function? 2. The rotator cuff is said to be part of a force couple. What does this mean? 3. The causative mechanisms for rotator cuff disease are divided into intrinsic and extrinsic factors. What are these? 4. Why are we concerned about the scapula position for this patient? 5. Why does this patient need good postural advice? 6. What are the complications of rotator cuff repair and what can be done to minimise the impact of these? 7. What will be included in the discharge planning for this patient? 8. What is the expected long-term outcome for this shoulder? CASE STUDY 2 Decompression/discectomy Subjective assessment PC 36-year-old male architect presents with a prolapsed intervertebral disc (PIVD) and is booked for a spinal decompression (L4/5) the next morning. The aims of surgery are to: decrease pain decompress the spinal nerve improve dural mobility to prevent adverse neural tension prevent or reduce neurological damage HPC History of recurrent back pain (but no leg pain) for many months with an insidious onset 7/52 ago, moved house and a few days later developed severe low back pain radiating into his right buttock and then, a few days later, into his right leg all the way down to his foot He was convinced that rest would alleviate this very sharp pain When this didn’t help, he was offered conservative treatment which also did not improve matters From thinking that he had a back strain he now started to worry that something quite serious was happening He also developed numbness on the outside of his lower leg A review with his consultant resulted in him being booked for surgery Objective assessment Investigations MRI – showed clear protrusion of L4/5 intervertebral disk onto the spinal nerve root and due to the worsening nature of his signs and symptoms it has been decided to decompress his lumbar spine Observation Patient has marked contralateral shift (away from his painful side) Can only sit for a very brief time Marked decrease in straight leg raise on the affected side Abnormal gait pattern of a shortened stride length on the affected side Pre-operative treatment aims Teach him bed exercises for circulation, breathing exercises and log rolling in bed Explain post-operative management and precautions Provide written information of post-operative management Fit him with a temporary lumbar corset Post-operative treatment Read operation report and check for any special instruction by surgeon Check wound if appropriate Reduce anxiety Identify and prevent any post-operative complications Monitor and restore respiratory function Check for any neurological abnormalities Get patient mobilised in his corset once muscular control of quadriceps and gluteus maximus has been demonstrated Educate patient regarding life after discharge: a. Recognition and prevention of complications b. Ergonomic advice c. Self-managed home exercise programme especially core stability and neural stretches ( Shacklock 2005 ) d. Advice on home activities including sitting, driving, working Enhance patient’s self-efficacy in his body Discharge criteria Usually discharged after 2–4 days depending on surgical procedure, wound state, neurological and muscular control Able to get dressed independently Able to use the toilet independently Sit for a minimum of 10 minutes Able to manage stairs Questions 1. What is a slipped disc? 2. What are the classic clinical features of a prolapsed intervertebral disc? 3. What is the differential diagnosis of prolapsed discs? 4. What red flag elicited in an examination of low back pain will need immediate action by a doctor? 5. Why is postural education and exercise important for this patient? 6. What psycho-social problems might influence this patient’s treatment outcome? CASE STUDY 3 Fractured neck of femur Subjective assessment PC 65-year-old very slightly built woman admitted via A&E with fractured neck of femur on the right Once the diagnosis has been confirmed by X-ray she is considered for total hip replacement (THR) The indications for surgery are: reduction of fracture reduction of pain increase of function HPC Patient fell on uneven paving stones in the street and immediately realised that she had ‘broken something’ Was in severe pain, unable to weight bear and had to be admitted to hospital by ambulance SH Lives alone, has a daughter in another city Completely independent and is a retired archivist Objective assessment Observation Her right leg appeared shortened and in external rotation in the A&E department X-ray Confirms fractured neck of femur – Garden classification stage III Pre-operative physiotherapy aims Introduce yourself to patient Find out about her anxieties Explain post-operative regime while still in bed Explain post-operative regime once she has been allowed to mobilise Breathing exercises Explain role of MDT Post-operative physiotherapy aims (rehabilitation starts on 1st day post surgery) Read operation report in notes and look for specific post-operative instructions by surgeon Reduce patient’s anxiety Check for post-operative complications Respiratory check and care as appropriate Start with vascular function maintenance (foot and ankle pumps) Introduce joint movement and muscle tone around the hip especially abduction and flexion, quadriceps and gluteus strength Bed mobility (especially bridging for toilet purposes) Keep abduction wedge when patient lies supine or lies on operated side Education about ‘do’s and don’ts (focussing on joint preservation and weight bearing) Confer with MDT (especially social worker) regarding possible hurdles to discharge (remember, she lives alone) Start mobilising with two crutches (usually by day 2–3 but check with medical colleagues) Reduce walking aid support to one stick (usually by day 4) Discharge usually by day 5 by which time she will need to be able to get in and out of bed on her own, sit to stand without help and manage to walk up and down a flight of stairs Overall aim: to enhance patient’s self-efficacy in her body Questions 1. What is the Garden classification of fractured neck of femur and how does it influence surgical management? 2. Is it typical for a fall to result in such severe injury in an elderly person? 3. What are possible post-operative complications? 4. What actions should the patient avoid until 6 weeks post operatively? 5. How would you start and then progress muscle re-education? 6. What could you do to assist this patient with her possible anxiety? CASE STUDY 4 Total knee arthroplasty/replacement Subjective assessment PC 71-year-old female admitted for an elective right total knee arthroplasty/replacement (TKR). The indications for surgery are: patello-femoral and tibia-femoral osteoarthritis demonstrated on X-ray pain interfering with and day-to-day activities including walking loss of right knee extension night pain failed course of conservative management and physiotherapy HPC Intermittent right knee pain and stiffness for at least 10 years but managed her pain with analgesia and rest Past 2 years pain has become more constant, her standing and walking tolerance has decreased and she is experiencing night pain The patient had one course of physiotherapy which included exercises, manual therapy and hydrotherapy. Therapy improved right knee extension but had no effect on pain Patient was referred by GP to an orthopaedic consultant where X-ray showed patello-femoral and tibial-femoral osteoarthritis The patient was offered an elective TKR PMH Nil of note SH Lives in a house with her husband who is fit and well No downstairs toilet and she does all the cooking and cleaning The patient is originally from Italy and still works in the family restaurant Objective assessment Gait/observation Antalgic gait, predominately weight bearing on her left lower limb Uses a stick on the right side There is a slight right knee varus deformity and a palpable patello-femoral joint crepitus There is no evidence of joint effusion or swelling Functional level Transfers independently in standing, sitting and supine positions Step-to pattern up and down stairs leading with left lower limb ROM Right knee ROM between 10° and 100° flexion All other peripheral upper and lower limb joints have normal range of movement Pre-operative treatment aims Teach bed exercises for circulation Teach deep-breathing exercises Explain post-operative management and introduce post-operative precautions Record right knee range of movement in the medical notes Teach patient to use appropriate walking aids correctly, including stairs Provide any written information sheets about post-operative care and discuss Post-operative treatment aims (day 1 and 2 post surgery) Read surgeon’s post-operative instructions regarding mobilisation Discuss with the MDT the patient’s health status and pain relief Assess bed exercises for circulation Assess deep breathing exercises to maintain good chest expansion Control post-operative knee joint swelling Commence knee joint passive and active range of movement according to the surgeons protocol Mobilize the patient according to the surgeons protocol for TKR Post-operative treatment aims (day 3 to discharge date) Discuss with patient and MDT the discharge goals Assess post-operative knee joint swelling Safe progression of all transfers between supine, sitting and standing Gait education with the appropriate use of walking aids Safe progression of stair mobility Progress active range of knee movement to 0–90° Assess the need of post-discharge physiotherapy? Education of the patient to include: a. Prevention of complications b. Self-managed home exercise programme c. Advice on home activity and gradual return to full independence Continuous passive motion machines, slings and springs and sliding boards are often used to increase the range of movement of the operative knee The discharge date is agreed when the patient can mobilise independently with or without walking aids, can mobilise on stairs independently and has achieved 90° degrees knee flexion Questions 1. What are the short-term and long-term goals for this patient and how can the therapist plan the post-discharge rehabilitation programme? 2. What is osteoarthritis? 3. What are the clinical features of osteoarthritis? 4. What can be considered conservative management for knee joint osteoarthritis? 5. Give examples of different types of total knee prosthesis 6. What are the post-operative complications of total knee replacement? CASE STUDY 5 Anterior cruciate ligament reconstruction Subjective assessment PC 35-year-old male is admitted to the ward for an elective left knee anterior cruciate ligament reconstruction (ACLR). The indications of surgery are: left anterior cruciate ligament (ACL) rupture patient is self-employed and he is not responding to conservative management HPC Patient injured his left knee 10/52 ago playing rugby when he fell forwards and sideways while the left foot remained fixed on the ground He felt immediate pain and was unable to continue with the game Pain and swelling increased over the next 2 hours X-rays taken in A&E were negative for fractures He was prescribed anti-inflammatories, referred to physiotherapy, given elbow crutches and advice on ice, rest and elevation A clinic appointment to see an orthopaedic consultant was arranged The patient had a physiotherapy assessment within 5/7 post injury and therapy focused on reduction of swelling and gentle mobility exercises 1/52 post injury the knee swelling had not reduced and the patient was still unable to weight bear on his left lower limb Soft tissue injury was difficult to assess and an urgent MRI scan was arranged which showed rupture of the left ACL and a medial collateral ligament tear The orthopaedic surgeon discussed conservative and surgical options and the patient consented to surgery as one of his main concerns was the physical requirements of his job and that he was self-employed SH Self-employed carpenter Married with two young children Plays rugby twice a week with friends and he is otherwise fit and well Objective assessment Observation Patient partially weight bearing with elbow crutches Slight muscle wasting of the left quadriceps muscles compared to the right lower limb Tenderness, heat and some swelling of the left knee joint but the patellofemoral joint is visible and palpable ROM The patient has lost 5° of knee extension and has 100° flexion Restricted by pain and swelling Knee extension is most painful movement Special tests Anterior drawer test in 70° knee flexion = positive (anterior tibial displacement) approximately 2 cm) was not conclusive due to pain and swelling Valgus stress instability was not conclusive due to pain and swelling Active Lachmans’ test was not assessed due to pain and swelling All other peripheral joints were documented as normal Pre-operative treatment aims Discuss aims and surgery procedure Explain that post-operative pain and swelling is a common presentation Discuss immediate post-operative plan Discuss and give written information of the post-operative protocol and rehabilitation programme Teach immediate post-operative knee joint exercises including patellofemoral mobilisations to maintain range of movement Teach safe mobilisation with elbow crutches Post-operative treatment aims (day 1 and 2 post surgery) Read surgeon’s post-operative instructions regarding mobilisation Minimise swelling with advice on rest, ice and elevation Advise patient on the importance of adequate pain relief Mobilise partially or fully weight bearing according to surgeon’s protocol. Encourage normal gait pattern and safe mobility on stairs. Mobilise with cricket bat splint or brace depending on surgeon’s protocol Commence active range of movement as instructed by surgeon’s protocol. Common protocols aim to achieve 0–90° of active range of movement by week 2 post surgery Encourage resting position in knee joint extension Plan discharge goals Discharge goals Reiterate ACL post-operative rehabilitation protocol and graft protection Discuss the importance of a graduated rehabilitation regime and good muscle control Discuss return to work according to surgeons protocol Review home exercise programme Review safe mobilisation on elbow crutches Re-assure the patient that immediate post-surgical pain and swelling will gradually reduce Arrange post-discharge out-patient physiotherapy appointment Questions 1. What is the role of the cruciate ligaments in knee joint stability? 2. Describe common ACL mechanisms of injury. 3. Why is reconstruction using grafts preferable to repair of torn tissue? What type of grafts can be used in ACL reconstruction? 4. Considering your patient’s profession what might be a better choice of graft for his ACL reconstruction? 5. The patient has post-operative pain and swelling and this is increasing his anxiety about his return to work. How can the therapist re-assure him and address this anxiety? 6. What is the clinical reasoning behind open and closed kinetic chain exercises in ACL reconstruction? CASE STUDY 6 Fractured tibia and fibula Subjective assessment PC 36-year-old male admitted via A&E for surgery after a motorbike accident a few hours earlier which resulted in several open transverse and crush fractures of his right tibia and fibula He also has deep friction burns on his left side from sliding on the road surface HPC Patient suffered massive blood loss due to the open nature of his fractures He was referred for immediate surgery Pedal pulses were weak but present and it was therefore decided to use an internal fixator to pin his leg After the surgery he was transferred to the high-dependency unit where his medical condition resulting from the blood loss can be monitored SH Self-employed motorcycle courier and a trained motorbike mechanic Lives with his partner and their three young children Patient and partner juggle their work schedule so that both look after their children without outside help Post-operative aims Read the operation report and check for any special post-operative instructions Check chest and start with breathing exercises Re-assure patient and advise him on process of rehabilitation Pain relief Check wounds (do not forget the left side with the burns) and distal pulses Advise patient on vascular exercises (e.g. foot and ankle pumps) for his left leg. No muscle contractions of his right lower leg yet as this may put strain on the bone ends As the patient will be non-weight bearing when he mobilises he will need to work his upper body and non-operated leg to achieve the endurance needed for this high effort walking pattern Questions 1. How are fractures classified? 2. What is an internal fixation? 3. What are the possible disadvantages of an ORIF? 4. What are the classic healing times for fractures? 5. What are the complications of fractures in general? 6. What model of rehabilitation and clinical reasoning might be useful for Mike? CASE STUDY 7 Achilles tendon repair Subjective assessment PC 41-year-old male has undergone an Achilles tendon (TA) repair 1/7 ago. You have been asked to ensure that he is safe to go home today on crutches HPC He ruptured his TA (the first time) 5/12 ago Treatment consisted of full leg plaster for 3/12 followed by out-patient physiotherapy 3/7 ago he was walking on level ground when it re-ruptured Previous diagnosis had been Achilles tendinopathy SH Lawyer working in city and travels in by underground Single and lives alone in first floor flat He plays squash at club level. Until 2 years before he had also been playing rugby at club level. From then till his TA ruptured first time he was refereeing rugby at least one game each weekend Objective assessment Observation Strong, fit looking man despite the long period of recent inactivity, with a below knee cast, the foot position being full plantar flexion Able to easily lift cast in all directions, has full mobility Circulation appeared normal Post-operative instructions Below knee cast with ankle in full plantar flexion 4/52, non-weight bearing Cast changed to reposition the foot into neutral, i.e. the ankle is at right angles, for a further 2/52, and a walking cast applied for weight bearing Cast removed 6/52 post surgery and out-patient physiotherapy to commence ( Dandy & Edwards 2003 ) Post-operative treatment aims To be clear with post-operation instructions To ensure safety with crutch walking on the flat and on stairs To support the patient psychologically Elbow crutches were supplied and fitted. Instructions for use were discussed and he was taken to the staircase for stair practice. No problems were encountered – balance, transfers and on ascending/descending the stairs. Throughout the session he revealed what an extremely difficult time he was having adapting to this long period of inactivity. This was discussed and the patient decided with help, that regular visits to the gym to work on upper body and contralateral leg (the unaffected leg) strength would give him some means of having control on this situation. He was deemed safe to go home and was discharged Questions 1. What is a tendinopathy? 2. How is a TA rupture diagnosed? 3. What muscles make up the TA and what is their function? 4. What are the stages of healing and how do they apply to this tendon? 5. Describe the progressive changes you think occur in the normal gait pattern when using crutches. 6. What are the complications of poor crutch walking? 7. What exercise therapy will likely to be incorporated into his rehabilitation once his plaster has been removed? CASE STUDY 8 Idiopathic scoliosis Subjective assessment PC 15-year-old girl admitted with idiopathic scoliosis. Scoliosis is thought to be progressing (Cobb angle 40°, Risser four) Booked in for a single stage anterior fusion in 2/7 The aim of the surgery is: to stabilise the spine to prevent further deterioration to correct the deformity HPC Change in patient’s spine was noticed by her mother 6/12 ago GP referred to consultant Pre-admission 8/52 ago – stayed overnight, met the MDT Postural advice with emphasis on symmetrical weight bearing was given Investigations including new spinal X-rays and chest X-ray, blood tests, ECG and sleep studies were carried out SH Sitting GCSE exams at the end of year and very worried about having time off school Used to play netball but lately finds it too difficult but would like to be able to play again Not involved in other sport as she feels awkward Objective assessment Observation Right rib ‘hump’ (thoracic right convex) with right shoulder protracted and a prominence of the right hip, i.e. the trunk has shifted to the left Curves well hidden under loose clothing Leg length Indicates a shortening of right leg Neurological signs Nil Single leg stance Difficult on both sides due to asymmetrical weight distribution Gait Normal Pre-operative treatment aims Respiratory assessment – record lung function in medical notes to ascertain pre-operative values Explain post-operative management and introduce post-operative precautions Provide any written information sheets about post-operative care and discuss Post-operative treatment aims Identify and prevent post-operative complications Restore respiratory function Restore active muscle control Safe, functional rehabilitation and progression of mobility Education of the patient to include: a. ergonomic advice

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related posts:

Stay updated, free articles. Join our Telegram channel

Comments are closed for this page.

Full access? Get Clinical Tree

• Open access
• Published: 23 May 2024

Preoperative investigation practices for elective surgical patients: clinical audit

• Meseret Firde 1 &
• Tikuneh Yetneberk 1  

BMC Anesthesiology volume  24 , Article number:  184 ( 2024 ) Cite this article

266 Accesses

Metrics details

The findings of pre-operative investigations help to identify risk factors that may affect the course of surgery or post-operative recovery by contributing to informed consent conversations between the surgical team and the patient, as well as guiding surgical and anesthetic planning. Certainly, preoperative tests are valuable when they offer additional information beyond what can be gathered from a patient’s history and physical examination alone. Preoperative testing practices differ significantly among hospitals, and even within the same hospital, clinicians may have varying approaches to requesting tests. This study aimed to investigate preoperative testing practices and compare them with the latest guidelines from the National Institute for Health and Care Excellence (NICE).

This three-month institutionally based study was carried out at the Debre Tabor Comprehensive Specialized Hospital from May 1 to July 30, 2023, including individuals aged 16 years and older who were not pregnant and had undergone elective surgery in the gynecological, orthopedic, and general units. Data on the sociodemographic characteristics, the existence of comorbidities, the invasiveness of surgery, and the tests taken into consideration by the guideline were gathered using a self-administered questionnaire. After rigorously analyzing and revising the results of preoperative investigation approaches, we compared them to the standard of recommendations. Moreover, the data was analyzed and graphically presented using Microsoft Excel 2013.

During the data collection period, 247 elective patients underwent general, orthopedic, and gynecological operations. The majority of patients, 107 (43.32%), were between the ages of 16 and 40 and had an American Society of Anesthesiologists (ASA) class one (92.71%). 350 investigations were requested in total. Of these, 71 (20.28%) tests were ordered without a justified reason or in contravention of NICE recommendations.

Conclusions

In our hospital’s surgical clinical practice, unnecessary preoperative testing is still common, especially when it comes to organ function tests, electrocardiograms (ECGs), and complete blood counts (FBCs). When deciding whether preoperative studies are required, it is critical to consider aspects including a complete patient history, a physical examination, and the invasiveness of the surgery.

Peer Review reports

Introduction

Preoperative investigations (PI) are tests performed prior to surgery to improve patient outcomes through planning, stratification, optimization, and perioperative management. The use of laboratory tests has long been an element of the preoperative evaluation of a patient’s fitness for anesthesia and surgery [ 1 ]. PI for patients scheduled for elective surgery typically includes a complete blood count (CBC), assessments of organ function, blood sugar level, urine analysis, chest radiography (CXR), and an electrocardiogram (ECG) [ 2 ].

Preoperative investigations can be categorized as either routine or indicated. According to the American Society of Anesthesiologists, routine preoperative tests are those performed without a specific clinical reason or purpose to detect a disease or disorder in a patient who shows no symptoms [ 3 , 4 ]. Indicated tests are performed in response to a specific clinical need, such as confirming a diagnosis, evaluating the severity and advancement of a disease, or assessing the effectiveness of medication [ 5 ].

Preoperative tests are valuable when they offer information beyond what can be gathered solely from a patient’s medical history and physical examination [ 1 ]. Apart from assessing a patient’s suitability for surgery and anesthesia, PI plays a role in evaluating the advancement and severity of illnesses, anticipating postoperative complications, balancing the risks and advantages of surgery, and facilitating adjustments to the patient’s clinical treatment as necessary [ 5 , 6 ]. Furthermore, PI can establish a baseline for future comparison, particularly when interpreting possibly abnormal postoperative test findings that may be challenging to understand independently [ 7 , 8 ].

Preoperative testing practices exhibit significant variability across hospitals, and even within the same hospital, clinicians may adopt diverse approaches to PI requests. Despite their historical importance in pre-anesthetic assessment, numerous scientific studies in recent years have suggested that routinely ordering preoperative tests for generally healthy patients often offers limited value in identifying illnesses or influencing anesthetic care or outcomes [ 5 , 10 , 11 , 12 ]. A significant portion of routinely conducted investigations, which can be expensive, may result in false-positive or borderline findings, prompting the need for further tests. This could impose psychological and financial difficulties, as well as delays or cancellations of surgery, potentially heightening the risks of morbidity and mortality [ 13 , 14 ]. Furthermore, it can lead to inefficient resource allocation and an increased workload for laboratories, potentially compromising the quality of patient care.

Similarly, Dzankic et al. concluded that routine preoperative testing for hemoglobin, creatinine, glucose, and electrolytes may not be indicated in geriatric patients after conducting a prospective cohort study that evaluated the prevalence and predictive value of abnormal preoperative laboratory tests in 544 patients aged 70 years old undergoing non-cardiac surgery [ 15 ]. In a prospective study involving 400 patients that aimed to assess the effectiveness of preoperative investigations in identifying high-risk groups for complications, only 16% of the results showed abnormalities. However, of these abnormal results, only 0.013% prompted a change in perioperative management [ 16 ].

Instead, conducting a detailed patient medical history and physical examination is the most efficient way to detect abnormalities. Following this, only a few specifically chosen tests are administered, taking into account the patient’s condition, the complexity of the planned surgery, and the likelihood of blood loss [ 14 , 17 , 18 ]. A selected testing strategy reduces costs without sacrificing surgical safety or the quality of treatment [ 5 ].

Nowadays, there is a greater emphasis on low-value healthcare services [ 1 ]. Nowadays, when preoperative laboratory investigations are correlated with the patients’ histories and physical examinations, they are found to be beneficial and cost-effective, and there is a greater emphasis on low-value healthcare services [ 1 , 8 , 9 , 19 ]. Several organizations, including the National Institute of Health and Clinical Excellence (NICE) and the Canadian Anesthesiologists’ Society (CAS), have issued guidelines to standardize testing and reduce costs [ 20 ]. The purpose of this audit was to identify disparities between the preoperative investigation procedures followed at Debre Tabor Comprehensive and Specialized Referral Hospital (DTCSH) and the latest preoperative investigation guidelines provided by NICE [ 20 ]. Secondly, our aim was to identify commonly ordered routine tests and assess the frequency of abnormal findings.

Methodology

This three-month institutional-based study was carried out at the Debre Tabor Comprehensive Specialized Hospital from May 1 to July 30, 2023. The study included all patients older than 16 years who were not pregnant and were hospitalized for elective surgery under general or regional anesthesia in the orthopedic, gynecological, and general units during the study period. The study excluded patients scheduled for emergency surgeries, day-case surgery, cardiothoracic procedures, neurosurgery, and elective procedures under local anesthesia.

We used NICE recommendations as a standard for comparison since they are internationally accepted, clear, and easily applicable guidance, even in developing nations. By recommending which investigations to offer before minor, intermediate, and major surgery while taking particular comorbidities into account, this guideline addresses standard preoperative tests to reduce unnecessary testing. Likewise, the audit focused on the tests indicated in the recommendation, including resting echocardiogram, FBC, hemoglobin A1C (HbA1c) testing, hemostasis tests, and organ function tests.

A self-administered questionnaire that was constructed in compliance with the guidelines was used to collect the data. The nights before surgery, patients were asked about possible pregnancies and any undiscovered illnesses. On the day of surgery, at the end of the procedure, data pertaining to surgical invasiveness (major, intermediate, or minor) and PI (FBC, CXR, ECG, BUN, creatinine, electrolyte, coagulation profile, kidney and liver function test) was also gathered from the patient’s medical record and compared to the guideline for appropriateness. Aside from the preoperative investigations, the patient’s sociodemographic characteristics, such as age, gender, American Society of Anesthesiologists (ASA) status, and the presence and severity of comorbid illness, were recorded. It is preferred to collect data at the end of procedures to avoid missing tests that might be performed in the morning of surgery.

In addition, the results of each investigation were recorded after being assessed as normal or abnormal, depending on the laboratory report’s normal range. The data were securely collected by two masters of sciences degree (MSc) anesthetists who were not engaged in the clinical practice of preoperative investigation requests. The information gathered was inspected for completeness and accuracy. Moreover, the data was analyzed and graphically presented using Microsoft Excel 2013.

Operational definitions

Minor surgery: surgical procedures including Excision of skin lesion, Myringotomy tubes, Hysteroscopy and Endoscopy/Colonoscopy [ 21 ].

Intermediate surgery: surgical procedures including hernia repair, laparoscopic, cholecystectomy, arthroscopy and tonsillectomy [ 21 ].

Major surgery: surgical procedures including total abdominal hysterectomy, endoscopic resection of the prostate, lumbar discectomy, thyroidectomy, total joint replacement, lung operations, colonic resection, and radical neck dissection [ 21 ].

Recommended (appropriate) investigation: the test that is recommended to be performed or considered after consideration of the particular comorbidities, sociodemographic profile, and types of surgery [ 21 ]:

Normal value ranges were defined using the institution’s laboratory ranges.

Preoperative laboratory testing: Preoperative investigation was defined for the purposes of this audit as any component of a laboratory or imaging test performed before surgery and considered by the guidelines.

The study included 247 patients who had elective surgery throughout the data collection period. The majority of patients, 107 (43.32%), were between the ages of 16 and 40 and had an American Society of Anesthesiologists (ASA) class one score of 229 (92.71%). Cardiovascular abnormalities were the most common concomitant disease (9.64%), followed by endocrine (4.62%), respiratory (3.12%), and renal (2.8%). Only 27 patients had minor surgery, accounting for 10.93% of the cases. Table  1 .

The majority of patients (132) had general and urological surgery, while the remainder received orthopedic (70) and gynecological (45) procedures. During the data collection period, thyroidectomy (44), vaginal hysterectomy [ 22 ], and incision and drainage [ 18 ] were the most common operations performed in general surgery, gynecology, and orthopedics departments, respectively. Table  2 : Full blood count (FBC) and echocardiography (Echo) were the most common 240 (97.16) and infrequent 4 (1.62%) tests among 350 investigations requested on all 247 individuals, respectively. Table  3 .

When the type of surgery and ASA classification are taken into consideration for each component of the test requests, for example, out of 19 FBC tests requested by ASA 1 patients who had minor surgery, only 9 FBC tests were deemed appropriate based on NICE recommendations. Additionally, despite being indicated to have them prior to the procedure, none of the HA1cs were requested for the two ASA 2 patients who underwent major surgery. Table  3 .

Overall, contrary to NICE recommendations, FBC was performed inappropriately as part of the preoperative investigation in 45 patients. In one patient without a clear indication, a hemostasis test was performed as part of the preoperative investigation. One patient was subjected to unnecessary chest x-rays. For 5 patients (ECG) and 4 patients (urinalysis), there was no clear indication. On the other hand, despite being indicated by NICE, PT/PTT in 4 and HbA1c in 4 patients were not performed. Figure  1 .

The number of investigations that were conducted inappropriately indicated investigations that were not completed in accordance with NICE recommendations

Moreover, among the investigated laboratory and imaging workups, 8 FBC, 2 ECG, 1 KFT, 1 hemostasis, and 1 urine test showed abnormal results. In addition, the finding revealed that there was no patient whose investigations were conducted without a clear indication and whose results were found to be abnormal. Figure  2 .

Types of investigations and the frequency of abnormal findings

In this study, out of all the patients audited, a total of 350 investigations were requested. Among these, approximately 79.71% of the requested investigations were conducted following national guidelines. This aligns with findings from Sri Lanka, where adherence to national guidelines exceeded 75% [ 2 ]. Conversely, 71 tests (20.28%) were requested without proper justification, violating NICE guidelines. Research by Benarroch-Gampel et al. revealed that as many as 90% of patients underwent at least one preoperative test that wasn’t medically necessary [ 23 ]. The discrepancy in findings between their study and ours might be due to their use of different criteria for comparison and their retrospective review of patient records.

Our study’s results reveal that the FBC (240) test is the most frequently requested test, which differs from findings in a related study conducted in Sri Lanka and Texas. In those studies, the most commonly performed tests were ECG and hematological investigations, respectively [ 23 , 24 ]. The variation in findings may be due to differences in the study’s design, sample size, and the types of surgeries included. For example, the initial audit involved 123 individuals undergoing urologic surgery exclusively. This might be because urologic conditions are often associated with age-related comorbidities, particularly cardiovascular disease [ 25 , 26 ].

During the assessment of each investigation component for adherence to guidelines, it was observed that FBC was requested for nearly all patients as part of routine preoperative investigation before surgery (240 patients, 97.16%). Among these, 45 patients underwent unnecessary FBC requests, contrary to NICE guidelines. This proportion is notably higher than the findings of a previous study conducted in Sri Lanka, where 24 patients were subjected to unwarranted preoperative requests for complete blood count tests [ 24 , 27 ].

The difference in findings could be due to the fact that the study by Abayasinghe Chamika et al. focused solely on the urology unit, potentially limiting variation in clinicians’ preoperative testing requests. However, despite this, the NICE guidelines advise against routinely requesting FBC for all patients before surgery. Instead, NICE recommended considering FBC for patients undergoing major or complex surgery, as well as for ASA3 and ASA4 patients undergoing intermediate surgery [ 13 ].

Regarding ECG, NICE recommends considering ECG requests for ASA 2 patients undergoing intermediate or major surgery, ASA 3 or 4 patients undergoing minor surgery without available ECG results from the previous year, and ASA 1 patients aged 65 or older scheduled for major surgery. However, contrary to these guidelines, preoperative ECGs were requested for five patients. In contrast, a study by P. Ranasinghe et al. found that non-recommended ECGs were requested in 30.6% of all patients [ 2 ].

The discrepancy between our results and theirs may be attributed to the study’s larger sample size (356), and the authors’ use of an outdated version of the NICE recommendation for comparison. Although ASA 3/4 patients with chronic liver disease, those taking anticoagulants or needing treatment regimen adjustments, and those necessitating clotting status assessment before intermediate or major surgery are recommended to undergo a hemostasis workup, PT/INR testing was conducted for 1 patient without evident justification.

Another notable discovery from this audit is the underutilization of certain tests recommended by the guidelines. For instance, despite NICE’s recommendation, hemostasis profile testing was omitted for four individuals. Similarly, kidney function tests were not conducted for 5 patients, and HbA1c tests were not performed for 4 patients, despite being indicated by the guideline. While routine testing in generally healthy individuals has been debated, scientific evidence also advocates for selective testing tailored to factors such as the patient’s medical status, the complexity of the planned surgery, and the likelihood of blood loss [ 13 , 28 ]. Clinicians can confirm diagnoses, assess the severity and progression of diseases, and predict prognoses by utilizing the results of investigations performed on symptomatic and indicated patients [ 22 ].

The strength of this clinical audit is its potential to enhance patient safety and optimize healthcare delivery by identifying areas for improvement in preoperative investigation practice protocols. The first drawback of the audit was that it did not include who requested each test, as most patient cards do not record which practitioners requested particular investigations. The study’s second limitation is that it doesn’t look at whether patients who have abnormal results during or after surgery are given any special attention or therapy. Lastly, the study failed to evaluate the variables that lead to the over-ordering of preoperative investigations. Consequently, we advise that future investigators address the aforementioned constraints in their research on the ordering of preoperative examinations before surgery.

In our hospital’s surgical clinical practice, preoperative investigations, notably FBC, liver function tests, and ECG, are still being excessively prescribed. On the contrary, we found that specific tests like HbA1c and echocardiography are necessary but have not been conducted yet. Avoiding routine testing does not mean avoiding preoperative investigation altogether. Instead, it involves following guidelines and carefully selecting which preoperative investigations to perform based on a comprehensive history, a physical examination, and the nature of the planned surgery.

Recommendations

Based on the findings of the audit, the following suggestions are proposed:

Establish a clear, up-to-date, evidence-based national or institutional guideline for preoperative investigation protocols.

Ensure that this guideline is readily accessible at the location where preoperative investigation requests are made.

Regularly conduct audits to assess the effectiveness of these protocols in ensuring patient safety.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

American Society of Anesthesiologists

chest x-ray

electrocardiography

echocardiography-resting

full blood count

Hemoglobin A1C

Kidney Function

lung function tests

National Institute for Healthcare Excellence

preoperative investigation

Bock M, Fritsch G, Hepner DL. Preoperative laboratory testing. Anesthesiol Clin. 2016;34(1):43–58.

Article   PubMed   Google Scholar  

Ranasinghe P, Perera Y, Abayadeera A. Preoperative investigations in elective surgery: practices and costs at the national hospital of Sri Lanka. Sri Lankan J Anaesthesiol. 2010;18(1).

Pasternak LR, Arens JF, Caplan RA, Connis RT, Fleisher LA, Flowerdew R, et al. Practice advisory for preanesthesia evaluation: a report by the American society of anesthesiologists task force on preanesthesia evaluation. Anesthesiology. 2002;96(2):485–96.

Article   Google Scholar  

Apfelbaum JL, Connis RT, Nickinovich DG, Pasternak LR, Arens JF, Caplan RA, et al. Practice advisory for preanesthesia evaluation: an updated report by the American society of anesthesiologists task force on preanesthesia evaluation. Anesthesiology. 2012;116(3):522–38.

Kumar A, Srivastava U. Role of routine laboratory investigations in preoperative evaluation. J Anaesthesiol Clin Pharmacol. 2011;27(2):174–9.

Article   PubMed   PubMed Central   Google Scholar  

Bryson GL. Has preoperative testing become a habit? Can J Anaesth. 2005;52(6):557–61.

Kumar A, Srivastava U. Role of routine laboratory investigations in preoperative evaluation. J Anaesthesiol Clin Pharmacol. 2011;27(2):174.

Martin SK, Cifu AS. Routine preoperative laboratory tests for elective surgery. JAMA. 2017;318(6):567–8.

Kirkham KR, Wijeysundera DN, Pendrith C, Ng R, Tu JV, Boozary AS, et al. Preoperative laboratory investigationsrates and variability prior to low-risk surgical procedures. J Am Soc Anesthesiologists. 2016;124(4):804–14.

Google Scholar  

Taylor GA, Oresanya LB, Kling SM, Saxena V, Mutter O, Raman S, et al. Rethinking the routine: preoperative laboratory testing among American society of anesthesiologists class 1 and 2 patients before low-risk ambulatory surgery in the 2017 National surgical quality improvement program cohort. Surgery. 2022;171(2):267–74.

Benarroch-Gampel J, Sheffield KM, Duncan CB, Brown KM, Han Y, Townsend CM Jr, et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg. 2012;256(3):518.

Pawar D. Common post-operative complications in children. Indian J Anaesth. 2012;56(5):496–501.

Health NIf, Excellence C. Routine preoperative tests for elective surgery. NICE London; 2016.

Böhmer AB, Wappler F, Zwissler B. Preoperative risk assessment–from routine tests to individualized investigation. Deutsches Arzteblatt Int. 2014;111(25):437–45. quiz 46.

Dzankic S, Pastor D, Gonzalez C, Leung JM. The prevalence and predictive value of abnormal preoperative laboratory tests in elderly surgical patients. Anesth Analgesia. 2001;93(2).

McKee RF, Scott EM. The value of routine preoperative investigations. Ann R Coll Surg Engl. 1987;69(4):160–2.

CAS   PubMed   PubMed Central   Google Scholar  

Power LM, Thackray NM. Reduction of Preoperative investigations with the introduction of an anaesthetist-led preoperative assessment clinic. Anaesth Intensive Care. 1999;27(5):481–8.

Article   CAS   PubMed   Google Scholar  

Finegan BA, Rashiq S, McAlister FA, O’connor P. Selective ordering of preoperative investigations by anesthesiologists reduces the number and cost of tests. Can J Anesth. 2005;52(6):575.

del Mata-Miranda P, Cano-Matus M, Rodriguez-Murrieta N, Guarneros-Zapata M, Ortiz I. Unnecessary routine laboratory tests in patients referred for surgical services. Cirugía Y Cir (English Edition). 2016;84(2):121–6.

Alfakih K, Greenwood JP, Plein S. The 2016 update to NICE CG95 guideline for the investigation of new onset stable chest pain: more innovation, but at a cost? Clin Med. 2017;17(3):209.

O’Neill F, Carter E, Pink N, Smith I. Routine preoperative tests for elective surgery: summary of updated NICE guidance. BMJ. 2016;354:i3292.

Ferrando A, Ivaldi C, Buttiglieri A, Pagano E, Bonetto C, Arione R, et al. Guidelines for preoperative assessment: impact on clinical practice and costs. Int J Qual Health Care. 2005;17(4):323–9.

Benarroch-Gampel J, Sheffield KM, Duncan CB, Brown KM, Han Y, Townsend CM Jr., et al. Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery. Ann Surg. 2012;256(3):518–28.

Chamika A, de Silva C, Nanayakkara M, Abeygunasekera A. An audit of preoperative investigations in a urology unit. Sri Lanka J Surg. 2011;28(1).

McVary KT. BPH: epidemiology and comorbidities. Am J Manag Care. 2006;12(5 Suppl):S122–8.

PubMed   Google Scholar  

Lusty A, Siemens DR, Tohidi M, Whitehead M, Tranmer J, Nickel JC. Cardiac failure associated with medical therapy of benign prostatic hyperplasia: a population based study. J Urol. 2021;205(5):1430–7.

Chamika A, Chamini S, Mala N, Abeygunasekera A. An audit of preoperative investigations in a urology unit. Sri Lanka J Surg. 2011;28.

Thiruvenkatarajan V, Pruett A, Adhikary SD. Coagulation testing in the perioperative period. Indian J Anaesth. 2014;58(5):565–72.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Download references

Acknowledgements

We express our gratitude to the clinical team in the recovery room for their support in collecting data.

The preparation of this manuscript was not supported by any funding.

Author information

Authors and affiliations.

Department of Anesthesia, Debre Tabor University, Po.box: 272, Debre Tabor, Ethiopia

Meseret Firde & Tikuneh Yetneberk

You can also search for this author in PubMed   Google Scholar

Contributions

It was Meseret who formulated the concept, conducted the data analysis, and wrote the manuscript. Tikuneh assisted with question preparation, data evaluation for completeness, and manuscript preparation. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Meseret Firde .

Ethics declarations

Ethics approval and consent to participate.

The Debre Tabor University College of Health Science Ethical Review Committee in Debre Tabor, Ethiopia, provided ethical approval for this study. Written informed consent was obtained from the participants prior to the start of the interview.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Firde, M., Yetneberk, T. Preoperative investigation practices for elective surgical patients: clinical audit. BMC Anesthesiol 24 , 184 (2024). https://doi.org/10.1186/s12871-024-02557-y

Download citation

Received : 28 November 2023

Accepted : 10 May 2024

Published : 23 May 2024

DOI : https://doi.org/10.1186/s12871-024-02557-y

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Clinical audit
• Preoperative test
• Preoperative investigation
• Pre-anesthesia workup

BMC Anesthesiology

ISSN: 1471-2253

• Submission enquiries: [email protected]
• General enquiries: [email protected]

• Systematic Review
• Open access
• Published: 29 May 2024

Risk factors of chronic postoperative pain after total knee arthroplasty: a systematic review

• Junfei Li 1 ,
• Tingyu Guan 1 ,
• Yue Zhai 1 &
• Yuxia Zhang 2  

Journal of Orthopaedic Surgery and Research volume  19 , Article number:  320 ( 2024 ) Cite this article

213 Accesses

Metrics details

There is a lack of relevant studies to grade the evidence on the risk factors of chronic pain after total knee arthroplasty (TKA), and only quantitative methods are used for systematic evaluation. The review aimed to systematically identify risk factors of chronic postoperative pain following TKA and to evaluate the strength of the evidence underlying these correlations.

PubMed, Web of Science, Cochrane Library, Embase, and CINAHL databases were searched from initiation to September 2023. Cohort studies, case-control studies, and cross-sectional studies involving patients undergoing total knee replacement were included. A semi-quantitative approach was used to grade the strength of the evidence-based on the number of investigations, the quality of the studies, and the consistency of the associations reported by the studies.

Thirty-two articles involving 18,792 patients were included in the final systematic review. Ten variables were found to be strongly associated with postoperative pain, including Age, body mass index (BMI), comorbidities condition, preoperative pain, chronic widespread pain, preoperative adverse health beliefs, preoperative sleep disorders, central sensitization, preoperative anxiety, and preoperative function. Sixteen factors were identified as inconclusive evidence.

Conclusions

This systematic review clarifies which risk factors could be involved in future research on TKA pain management for surgeons and patients. It highlights those factors that have been controversial or weakly correlated, emphasizing the need for further high-quality studies to validate them. Most crucially, it can furnish clinicians with vital information regarding high-risk patients and their clinical attributes, thereby aiding in the development of preventive strategies to mitigate postoperative pain following TKA.

Trial registration

This systematic review has been registered on the PROSPERO platform (CRD42023444097).

Introduction

Total knee arthroplasty (TKA) is the most common surgical intervention for patients with end-stage osteoarthritis [ 1 ].Despite a positive outcome for most patients, a sizeable portion of individuals experience significant pain following TKA [ 2 ]. Previous studies showed that the percentage of patients with unfavorable long-term pain outcomes ranged 10% ∼ to 34% following knee replacement [ 3 ]. The International Association for the Study of Pain (IASP) defines chronic postoperative pain (CPSP) as pain that persists for more than 3 months after surgery, excluding other causes (e.g., infection, surgical failure, recurrence of malignancy, etc.) [ 4 ]. In addition to disruption of daily activities brought on by the pain itself, adverse or chronic pain outcomes following joint replacement are of great concern to orthopedic surgeons and their patients. Chronic postoperative pain is also associated with deterioration in physical, functional, and mental domains, which implies significant personal, social, and healthcare costs with the rising prevalence of knee replacement surgeries [ 5 ].

Understanding the risk factors affecting chronic postsurgical pain can help increase the clinical staff’s understanding of the field, which can help clinicians make better decisions and help patients reduce the risk of developing chronic pain. Previous pain guidelines have only recommended perioperative interventions without doing an integration of risk factors [ 6 ]. Earlier systematic reviews that applied quantitative measures to identify predictors of persistent pain after TKA, without considering the grading of evidence, may result in limited quality outcome [ 7 ].

Therefore, this study will conduct a systematic review and critical appraisal of the risk factors affecting chronic pain after TKA, and use the Newcastle-Ottawa Scale (NOS) and the Agency for Healthcare Research and Quality (AHRQ) checklist to quality rate the level of evidence in the included literature.

This article used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement to guide implementation and reporting [ 8 ].

Data sources and search strategy

Five databases were searched (PubMed, Web of Science, Cochrane Library, Embase, CINAHL) from the time of the foundation of the database to July 2023. All pertinent keyword variations were used, including both the Medical Subject Headings (Mesh) of various databases as well as the free-text versions of these terms. Reference lists of selected studies and reviews were searched to find additional publications on the subject. Detailed information about the search strategy is shown in Appendix 1 .

Study selection and eligibility criteria

Studies meeting the following criteria were included: (1) cohort studies or case-control or cross-sectional studies; (2) patients undergoing total knee arthroplasty who are aged above 18 years old; (3) the outcome was defined as postoperative pain following total knee arthroplasty and follow-up had to be at least three months; (4) outcomes were predicted using preoperative, intraoperative or postoperative conditions. If total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients were both included in the study, only TKA data were extracted. The exclusion criteria were as follows: (1) publications written in languages other than English and Chinese, (2) studies with incomplete methodology and full text not available. In addition, given the large number of possible confounding variables, cohort studies that failed to use a multivariate approach to assess risk factors were excluded.

Screening and data extraction

The titles and abstracts of all preliminary identified studies were screened by two investigators (JL and TG) independently following the selection criteria. Any differences of opinion were settled by consensus or discussion with a third independent reviewer. If there were multiple publications available, the most recent data were taken. To gather pertinent data, a predesigned electronic data extraction form was used. If there were multiple publications available, the most recent data were taken. The following information was extracted: participant characteristics, risk factors, pain outcome measures, follow-up period, and study design.

Assessing the risk of bias

The risk of bias assessment was independently assessed by two authors (JL and TG) in each included study by using the Newcastle Ottawa Quality Assessment Scale (NOS) and the checklist recommended by the Agency for Healthcare Research and Quality (AHRQ) [ 9 ].

The Newcastle-Ottawa Scale (NOS) is an important tool that evaluates case-control and cohort studies. It is composed of three main sections, which include a total of eight items. These sections cover various aspects of the study, including the selection of the study population, comparability, and exposure/outcome evaluation. The NOS uses a semi-quantitative star system to rate the study’s quality, with a maximum score of nine stars. Studies were categorized as high quality (7–9 points), moderate quality (4–6 points), and low quality (0–3 points) [ 10 ]. To evaluate the quality of the cross-sectional studies, we utilized the checklist recommended by the Agency for Healthcare Research and Quality (AHRQ). The AHRQ Risk of Bias Evaluation Tool assesses the risk of bias in five domains, including selection bias, implementation bias, follow-up bias, detection bias, and reporting bias. If the answer was “no” or “unclear”, the score was 0. If the answer is “yes”, the score is 1. Articles are rated as low (0–3), moderate (4–7), or high quality (8–11) [ 11 ].

Data synthesis and analysis

Semi-quantitative methods were used to summarize the strength of evidence supporting the association between risk factors and chronic postoperative pain. The best evidence synthesis included variables that were examined using a multivariate approach in at least two studies and demonstrated a statistically significant association. Three criteria were used to quantitatively evaluate the evidence of risk factors for chronic pain following total knee replacement: (1) the number of studies evaluating the variables; (2) the standard of the scores for each variable under assessment; (3) the consistency of the relationship between the factors and chronic postoperative pain. When 75% of the studies evaluating the variable reported the same direction of association, associations were deemed consistent [ 12 ]. Variables analyzed using multivariate methods that yielded no association were also taken into account. The level of evidence on risk factors for postoperative chronic pain was categorized into the following four categories: (1) strong: consistent findings were found in ≥ 2 high-quality articles; (2) moderate: with consistent results between 1 high-quality article and ≥ 1 moderate quality article or ≥ 3 moderate or low-quality articles; (3) inconclusive: When observed associations are inconsistent or assessed in 1 high-quality, < 3 moderate-quality studies or only in low-quality studies; (4) no association: no significant association was found in the high-quality multivariate analysis, or at least 3 high-quality studies found no association in the univariate analysis.

Study identification

Database search returned 18,792 articles, and 7 relevant articles were obtained through supplements from other resources. A total of 17,526 articles were obtained after eliminating duplicates. 17,239 references were excluded from the initial screening by reading titles and abstracts, leaving 287 references for full-text review. Among the remaining articles, 105 did not cover the outcome of concern, 66 did not match the target population, the full text was not available for one study, and 61 were excluded for other reasons. Therefore, a total of 32 studies were included in the systematic evaluation including five cross-sectional studies, one case-control study, and 26 cohort studies. The flowchart and reasons for exclusion are delineated in Fig.  1 .

Flowchart of study selection

Study characteristics

A total of 32,645 patients who underwent primary total knee arthroplasty were enrolled in this study (see Table  1 ). The sample size ranged from 71 to 11,373. The commonly used outcome measurement instruments in the studies were the visual analog scale (VAS) (10 studies), Western Ontario and McMaster Osteoarthritis Index (WOMAC) pain scale (8 studies), and the Numerical Rating Scale (NRS) (7 studies). Five studies included total knee arthroplasty and total hip arthroplasty from which we extracted data for TKA. Study follow-up lasted a minimum of 3 months and a maximum of 10 years. Furthermore, 29 predictive factors associated with the development of postoperative chronic pain after TKA were identified.

Methodologic quality of included reviews

The research primarily focused on high or medium-quality literature, with no low-quality literature included in the analysis. The quality of cohort studies was evaluated using the NOS scale, with ratings ranging from moderate (four) to high (nine). The case-control study received a score of six out of nine on the NOS scale, indicating a moderate level of evidence. Five cross-sectional studies were assessed for quality using AHRQ, with three receiving a high-quality rating and two receiving a moderate rating. The scores for these studies ranged from 6 to 11. In studies rated as moderate quality, the most frequent reasons were attributed to the presence of confounding and measurement bias. Nine cohort studies have not reported or controlled for confounders, which may have led to an elevated risk of confounding bias. Furthermore, four cross-sectional studies exhibited indications of measurement bias, and the handling of missing data were not disclosed in the publication. The quality evaluation of the included studies according to the NOS and AHRQ checklist are shown in Appendix 2 .

The level of evidence for risk factors

Twenty-nine risk factors associated with the incidence of postoperative chronic pain were identified. The results of the best evidence analysis are presented in Table  2 . Upon conducting the study, it was found that ten variables exhibited a significant association with the onset of chronic pain following total knee arthroplasty (TKA). Age, body mass index (BMI), and comorbidities condition were discovered to possess strong evidence among demographic variables. As for preoperative factors, strong evidence was observed for preoperative pain, chronic widespread pain, preoperative adverse health beliefs, preoperative sleep disorders, central sensitization, preoperative anxiety, and preoperative function. No risk factors were strongly associated with the development of chronic pain among intraoperative and postoperative factors. Additionally, three factors were found to have a moderate association with outcome variables, namely gender, preoperative depression, and pain trajectory. At length, sixteen risk factors were identified as inconclusive, with the majority of them being statistically linked to chronic pain after TKA in just one study.

A total of 32 studies were included in our review, with a focus on case-control, cohort, and cross-sectional studies, and the grade of evidence in the literature was evaluated using the NOS scale, a quality assessment tool for cohort/case-control studies, and the AHRQ, a quality assessment tool for cross-sectional studies. Overall, the quality level of literature included in this study was high, and the reason for articles with a moderate level of evidence rating was the presence of potential confounding bias or measurement bias in the study. Twenty-nine risk factors connected with the development of chronic postoperative pain were identified, among which ten exhibited a strong correlation, three showed a moderate correlation, and sixteen factors yielded inconclusive results.

We employed a semi-quantitative approach to evaluate the level of evidence for risk factors and, in contrast to previous studies, identified two novel factors that exhibit a strong association with chronic pain following knee replacement surgery: preoperative sleep disturbances and preoperative poor health beliefs.

According to recent research that utilized machine learning and a large sample size, it has been determined that sleep problems can have a significant impact on chronic pain [ 13 ]. When we sleep, our body’s natural pain relief system is activated, and any disruptions to this system due to sleep deprivation or disturbances can negatively affect it [ 14 ]. A study was conducted to delve deeper into the relationship between sleep quality before total knee arthroplasty surgery and postoperative chronic pain syndrome (CPSP) [ 15 ]. The findings revealed that individuals who experienced sleep problems before the surgery were more likely to report higher pain scores three months after the procedure. This highlights the importance of addressing any pre-existing sleep issues before undergoing surgery to minimize the risk of postoperative chronic pain.

Health beliefs are thoughts, attitudes, or expectations that influence the experience of health and illness and related behaviors. Predictors such as illness perception, pain catastrophizing, preoperative expectations, and coping attitudes were grouped into the category of preoperative health beliefs in our article. Seven high-quality articles and one moderately quality article have demonstrated a statistically significant correlation between preoperative negative health beliefs and chronic postoperative pain [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Research has shown that patients who experience greater levels of preoperative pain catastrophizing are more likely to suffer from moderate to severe pain after surgery. A study conducted by Giusti et al. has revealed that behavioral outcomes can forecast pain and functional outcomes up to 12 months after surgery [ 24 ]. Additionally, the study suggests that these outcomes partially mediate the relationship between catastrophizing and subsequent pain and function. Furthermore, a cohort study has identified the existence of psychological risk factors that may hinder the implementation of proper pain coping strategies and lead to the development of chronic postoperative pain.

Our review identified sixteen factors with insufficient evidence, as they were only statistically associated with CPSP in one study upon critical appraisal and lacked support from other literature. This highlights the necessity for further validation of these under-evidenced factors in future studies, specifically investigating their association with chronic pain. Moreover, it is crucial to prioritize factors backed by robust evidence and develop interventional clinical protocols based on these high-risk factors to provide comprehensive guidance to clinicians and nurses.

Limitations

This study has several limitations. In this systematic review, we only included patients with primary TKA and excluded those undergoing revision surgery and uni-compartmental arthroplasty; therefore, our findings may not extrapolate to other types of patients.

One of the major challenges in our study was the heterogeneity in the design of the included studies. We also found variations in the outcome indicators and measurement techniques used, which might account for the discrepancies in the results and hinder the integration of these findings.

Furthermore, we observed that some of the studies analyzed in this review did not adjust for potential confounders in their analyses. Confounding could have contributed to bias in our findings to some extent. Therefore, we recommend that future studies should put these factors into consideration when analyzing their results.

Clinical implications

This systematic review can inspire future personalized pain prevention and management measures. Enhanced monitoring of patient-reported pain before and early after surgery may lead to early detection and potential early intervention of patients at risk for CPSP. Early identification and targeted treatment of pain may reduce pain and prevent long-term disability. Improving awareness of the importance of biological, sociocultural, psychological, physical, and clinical factors will help to implement the role of interventions better.

This systematic review aims to assess the risk factors that contribute to the emergence of chronic pain after total knee arthroplasty. It further endeavors to appraise the evidence supporting these factors quantitatively. This analysis strives to enlighten surgeons and patients alike on potential risk factors that deserve exploration in future TKA pain management research, particularly those that have generated controversy or displayed weak correlations. Importantly, it underscores the necessity for additional high-quality studies to confirm these factors, thereby equipping clinicians with crucial knowledge regarding high-risk patients and their clinical characteristics. In turn, this knowledge contributes to the formulation of effective preventive measures aimed at reducing postoperative pain following TKA.

Data availability

No datasets were generated or analysed during the current study.

Hamilton D, Henderson GR, Gaston P, MacDonald D, Howie C, Simpson AH. Comparative outcomes of total hip and knee arthroplasty: a prospective cohort study. Postgrad Med J. 2012;88(1045):627–31.

Article   PubMed   Google Scholar  

Fuzier R, Rousset J, Bataille B, Salces-y-Nédéo A, Maguès JP. One half of patients reports persistent pain three months after orthopaedic surgery. Anaesth Crit Care Pain Med. 2015;34(3):159–64.

Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open. 2012;2(1):e000435.

Article   PubMed   PubMed Central   Google Scholar  

Schug SA, Lavand’homme P, Barke A, Korwisi B, Rief W, Treede RD. The IASP classification of chronic pain for ICD-11: chronic postsurgical or posttraumatic pain. Pain. 2019;160(1):45–52.

Kim DH, Pearson-Chauhan KM, McCarthy RJ, Buvanendran A. Predictive factors for developing chronic Pain after total knee arthroplasty. J Arthroplasty. 2018;33(11):3372–8.

Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: enhanced recovery after surgery (ERAS(®)) Society recommendations. Acta Orthop. 2020;91(1):3–19.

Lewis GN, Rice DA, McNair PJ, Kluger M. Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis. Br J Anaesth. 2015;114(4):551–61.

Article   CAS   PubMed   Google Scholar  

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.

Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603–5.

Martínez-González L, Fernández-Villa T, Molina AJ, Delgado-Rodríguez M, Martín V. Incidence of Anorexia Nervosa in women: a systematic review and Meta-analysis. Int J Environ Res Public Health. 2020;17(11).

Liu L, Cai XC, Sun XY, Zhou YQ, Jin MZ, Wang J, et al. Global prevalence of metabolic syndrome in patients with psoriasis in the past two decades: current evidence. J Eur Acad Dermatol Venereol. 2022;36(11):1969–79.

Gosselt AN, Slooter AJ, Boere PR, Zaal IJ. Risk factors for delirium after on-pump cardiac surgery: a systematic review. Crit Care. 2015;19(1):346.

Miettinen T, Mäntyselkä P, Hagelberg N, Mustola S, Kalso E, Lötsch J. Machine learning suggests sleep as a core factor in chronic pain. Pain. 2021;162(1):109–23.

Haack M, Simpson N, Sethna N, Kaur S, Mullington J. Sleep deficiency and chronic pain: potential underlying mechanisms and clinical implications. Neuropsychopharmacology. 2020;45(1):205–16.

Luo ZY, Li LL, Wang D, Wang HY, Pei FX, Zhou ZK. Preoperative sleep quality affects postoperative pain and function after total joint arthroplasty: a prospective cohort study. J Orthop Surg Res. 2019;14(1):378.

Yan Z, Liu M, Wang X, Wang J, Wang Z, Liu J, et al. Construction and Validation of Machine Learning Algorithms to Predict Chronic Post-surgical Pain among patients undergoing total knee arthroplasty. Pain Manag Nurs; 2023.

Lindberg MF, Miaskowski C, Rustøen T, Cooper BA, Aamodt A, Lerdal A. Preoperative risk factors associated with chronic pain profiles following total knee arthroplasty. Eur J Pain. 2021;25(3):680–92.

Shim J, McLernon DJ, Hamilton D, Simpson HA, Beasley M, Macfarlane GJ. Development of a clinical risk score for pain and function following total knee arthroplasty: results from the TRIO study. Rheumatol Adv Pract. 2018;2(2):rky021.

Rice DA, Kluger MT, McNair PJ, Lewis GN, Somogyi AA, Borotkanics R, et al. Persistent postoperative pain after total knee arthroplasty: a prospective cohort study of potential risk factors. Br J Anaesth. 2018;121(4):804–12.

Yakobov E, Scott W, Stanish W, Dunbar M, Richardson G, Sullivan M. The role of perceived injustice in the prediction of pain and function after total knee arthroplasty. Pain. 2014;155(10):2040–6.

Sullivan M, Tanzer M, Reardon G, Amirault D, Dunbar M, Stanish W. The role of presurgical expectancies in predicting pain and function one year following total knee arthroplasty. Pain. 2011;152(10):2287–93.

Riddle DL, Wade JB, Jiranek WA, Kong X. Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clin Orthop Relat Res. 2010;468(3):798–806.

Larsen DB, Laursen M, Edwards RR, Simonsen O, Arendt-Nielsen L, Petersen KK. The combination of Preoperative Pain, conditioned Pain Modulation, and Pain Catastrophizing predicts Postoperative Pain 12 months after total knee arthroplasty. Pain Med. 2021;22(7):1583–90.

Giusti EM, Manna C, Varallo G, Cattivelli R, Manzoni GM, Gabrielli S et al. The predictive role of executive functions and psychological factors on Chronic Pain after Orthopaedic surgery: a longitudinal cohort study. Brain Sci. 2020;10(10).

Download references

This study was supported by the National Key R&D Programmes (NKPs) subproject of China, Grant Numbered: No.2020YFC2008404-3.

Author information

Authors and affiliations.

Fudan University, Shanghai, China

Junfei Li, Tingyu Guan & Yue Zhai

Zhongshan Hospital, Shanghai, China

Yuxia Zhang

You can also search for this author in PubMed   Google Scholar

Contributions

Study concept and design: Junfei Li, Yuxia Zhang. Data acquisition analysis, or interpretation: Junfei Li, Tingyu Guan. Quality assessment: Junfei Li, Tingyu Guan. Manuscript preparation: Junfei Li. Critical revision of the manuscript: Yue Zhai, Yuxia Zhang. Study supervision and obtained funding: Yuxia Zhang. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Yuxia Zhang .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Supplementary material 2, rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Li, J., Guan, T., Zhai, Y. et al. Risk factors of chronic postoperative pain after total knee arthroplasty: a systematic review. J Orthop Surg Res 19 , 320 (2024). https://doi.org/10.1186/s13018-024-04778-w

Download citation

Received : 03 April 2024

Accepted : 02 May 2024

Published : 29 May 2024

DOI : https://doi.org/10.1186/s13018-024-04778-w

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Chronic pain
• Pain, postoperative
• Arthroplasty, replacement, knee
• Risk factor

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X

• Submission enquiries: [email protected]

Gestational Diabetes Risk and Low Birth Weight After Metabolic Bariatric Surgery: a Complex Interplay to be Balanced

• Original Contributions
• Open access
• Published: 04 June 2024

Cite this article

You have full access to this open access article

• Diana Rodrigues-Martins 1 , 2 , 3 ,
• Sara Andrade 2 , 3 ,
• Sofia S. Pereira 2 , 3 ,
• Jorge Braga 1 ,
• Inês Nunes 4 , 5 &
• Mariana P. Monteiro   ORCID: orcid.org/0000-0002-0662-1831 2 , 3 , 6  

Introduction

Metabolic bariatric surgery (MBS) is known to improve the obstetric outcomes of women with obesity and to prevent gestational diabetes (GD). To what extent does MBS decreases GD, without incurring at additional risks is a matter of concern.

A retrospective case–control study to compare the pregnancy outcomes of women previously submitted to MBS to those of age and preconception body mass index (PC BMI) matched non-operated controls.

Pregnancies of women after MBS ( n  = 79) and matched controls ( n  = 79) were included. GD was significantly less frequent after MBS (7.6% vs. 19%; p  = 0.03). Fasting blood glucose (76.90 ± 0.77 vs 80.37 ± 1.15 mg/dl, p  < 0.05; 70.08 ± 1.34 vs. 76.35 ± 0.95 mg/dl; p  < 0.05, first and second trimesters respectively) and birth weight (2953.67 ± 489.51 g vs. 3229.11 ± 476.21 g; p  < 0.01) were significantly lower after MBS when compared to controls. The occurrence of small-for-gestational-age (SGA) was more frequent after MBS (22.8% vs. 6.3%; p  < 0.01), but no longer significant after controlling for smoking habits (15.5% vs. 6%, p  = 0.14). There were no significant differences in gestational weight gain, prematurity rate nor mode of delivery between groups.

MBS was associated with a lower prevalence of GD than observed in non-operated women with the same age and BMI. After controlling for smoking, this occurred at the expense of a lower birth weight. Our data reinforces the hypothesis that MBS has body weight independent effects on glucose kinetics during pregnancy with distinctive impacts for mother and offspring, which need to be balanced.

Graphical Abstract

Avoid common mistakes on your manuscript.

In parallel to the rising prevalence of obesity in the general population, the prevalence of obesity in women during pregnancy is also increasing, which is estimated to range between 7 and 25% in Europe [ 1 , 2 ]. Women with obesity are at increased risk of short- and long-term pregnancy complications for both mother and kindred [ 3 ]. Adverse obesity-related pregnancy outcomes include gestational diabetes (GD), hypertensive disorders of pregnancy (HDP), prematurity, cesarean delivery, perinatal mortality, and congenital malformations [ 4 ].

Given that metabolic bariatric surgery (MBS) is being increasingly performed in women at reproductive age, pregnancies after MBS are also becoming progressively more frequent [ 5 , 6 ]. The available evidence shows that MBS is associated with a significant reduction in the risk of several obesity-associated diseases and most particularly GD [ 7 ]. However, concerns have also been raised on the potential harms, such as fetal growth restriction (FGR) and small-for-gestational-age (SGA) infants [ 8 , 9 ]. In a recent meta-analysis, pregnant women after MBS matched for preconception (PC) BMI to non-operated controls were shown to be at increased risk of SGA infants and preterm delivery, suggesting that despite the benefits, surgery also carries additional risks. However, given that the risk for adverse obstetric outcomes was higher than observed in women matched for PC BMI, suggests that these could be independent of BMI [ 8 ]. Notwithstanding, data interpretation is hampered by the heterogeneity of populations, as most of the original evidence available on MBS and pregnancy outcomes derives from case–control studies [ 10 ] and the fact that controls were not always comparable regarding body mass index (BMI) and maternal age [ 11 ]. Consequently, it is not entirely clear whether the benefits, as well as the risks on maternal and neonatal outcomes, are solely the end result of weight loss or whether there is also a contributing role of surgery, itself. Therefore, aim was to compare the obstetric and neonatal outcomes of women previously submitted to MBS to those of non-operated women matched for age and PC BMI.

Materials and Methods

Study design and population.

This was a retrospective case–control study that included pregnant women submitted to MBS and non-operated controls, admitted for prenatal care and delivery at a single public academic tertiary center, from January 2018 to December 2021. Twin pregnancies, pregnancies resulting from medical-assisted reproduction, or pregnancies which deliveries occurred at another institution, were pre-established exclusion criteria.

Electronic medical records were used for data retrieval. SGA was defined as birth weight < 10th percentile, based on race-ethnicity-, and sex-specific birth weights for gestational age cutoffs [ 12 ]. In non-operated controls, GD diagnosis was performed according to International Association of the Diabetes and Pregnancy Study Group guidelines and criteria, by assessing fasting glucose during the first trimester, which if normal (< 92 mg/dl) was followed by a subsequent screening test between 24–28 gestation weeks, with a 75 g oral glucose tolerance test (OGTT) [ 13 ]. In those women after MBS, not previously diagnosed with GD with fasting glucose at first trimester, capillary glucose self-monitoring before and after main meals up to six times daily for 2 weeks, between 24 and 28 gestational weeks was used given the OGTT limitation in this population.

Control Matching Process

Potential non-operated controls were identified among pregnant women attending the center during the same time interval and selected for inclusion by age and PC BMI matching, implementing a propensity score analysis using the XLSTAT add-on for Microsoft Excel®. Thus, for each post-surgery delivery, one control delivery was matched by maternal PC BMI and maternal age at conception, in order to ensure homogeneity of the comparing groups.

The pre-established primary outcome of this study was the occurrence of major obstetric complications, namely GD, HDP, SGA, and neonatal intensive care unit (NICU) admission. The secondary outcomes were gestational weight gain (GWG), mode of delivery, newborn body weight, and maternal complications during puerperium.

Statistical Analysis

The statistical analysis involved descriptive statistics, namely absolute and relative frequencies, means and standard deviations, and inferential statistics. The normality of distribution was analyzed with the Shapiro–Wilk test and the homogeneity of variances with Levene’s test. The chi-square and Fisher’s tests were used to compare categorical variables. For the continuous variables, the Student’s t -test and Mann–Whitney test were used, depending on variables normality. According to variable category, linear or logistic regression analysis was performed to evaluate if pre-operative BMI was associated with pregnancy outcomes. A logistic regression analysis was used to identify predictors of SGA.

The significance level for rejecting the null hypothesis was set at (α) ≤ 0.05. Statistical analysis was performed with SPSS Statistics® program, version 28.0.

Women submitted to MBS prior to conception were identified among those admitted for antenatal care during the pre-specified time period ( n  = 91). After applying the exclusion criteria, 12 pregnancies were excluded for the following reasons: delivery at another institution ( n  = 9), pregnancy after assisted reproduction techniques ( n  = 2) and twin pregnancy ( n  = 1), yielding the final number of eligible pregnancies for analysis ( n  = 79), which were pair matched to controls ( n  = 79) as above described. Women who underwent MBS clinical features before surgery and conception are displayed at Table  1 . Besides age and PC BMI, operated and non-operated women were also matched for other non-specified clinical features and despite smoking before and/or during pregnancy being more frequent in the MBS group, the difference was not statistically significant (26.6% vs. 15.2%; p  = 0.08) (Table  2 ).

Significant differences in the pre-specified pregnancy outcomes were identified between groups—namely GD was less frequent in the MBS group (7.6% vs. 19%; p  = 0.03). First and second trimester fasting glucose, birth weight and newborn height were significantly lower in MBS group, while the frequency of SGA (22.8% vs. 6.3%; p  < 0.01) was higher in MBS group compared to controls (Table  3 ). NICU admission occurred in four newborns of the MBS group (severe fetal growth restriction ( n  = 1), renal malformation with pulmonary dysplasia ( n  = 1), neonatal bradycardia ( n  = 1) and respiratory distress ( n  = 1)) and in a newborn of the control group (due to prematurity) (5.1% vs. 1.3%; p  = 0.37). No neonatal deaths occurred. Maternal complications during puerperium were more frequent in the MBS group (17.7% vs. 5.1%; p  < 0.01), being anemia and wound infections the most accountable entities ( p  = 0.01 and p  = 0.03 respectively) (Table  3 ). There were no significant differences between groups regarding gestational age at delivery, induction of labor or mode of delivery.

On regression analysis, pre-operative BMI was not found to be significantly associated with any of the pregnancy outcomes (supplementary Table  1 ), while smoking was the only variable found to be associated with a higher risk of SGA (supplementary Table  2 ). Hence, a subanalysis excluding pregnancies from smoking mothers was then performed to disentangle the influence of this variable on pregnancy outcomes. From this subanalysis, fasting glucose at 24–28 gestational weeks, birth weight and birth height remained significantly lower; however, the SGA frequency was no longer statistically different in the MBS group when compared to control group (15.5% vs. 6%; p  = 0.14) (Table  4 ). A sub-group analysis comparing pregnancies of women who conceived < 12 months vs > 12 month after MBS to evaluate the potential impact on birth weight and the occurrence of SGA was performed, but no significant differences were found between the groups (supplementary Table  3 ).

MBS is a highly effective weight loss intervention and weight loss decreases the risk of adverse obstetric outcomes in women with obesity. However, to what extent is MBS able to revert the risk of obesity-associated obstetric complications towards the levels of age and BMI matched women, without incurring at additional surgical-related risks, is not entirely known [ 3 , 7 ]. Therefore, to address this knowledge gap, we decided to compare the pregnancy outcomes of women previously submitted to MBS to those of non-operated women matched for age and PC BMI.

Our study shows that GD was significantly less frequent, while birth weight was significantly lower after MBS when compared to age and PC BMI matched controls, after controlling for smoking.

Our case–control study matched for PC BMI, which contrasts to previous studies that used pre-surgery BMI as control [ 14 ], allowed us to further explore and disentangle the effects of MBS at reducing the incidence of GD beyond the weight loss achieved. At first glance, our study findings corroborate the previously available evidence on GD after MBS [ 7 , 15 , 16 ]. Furthermore, despite there were no differences regarding PC BMI and age, our finding of a lower fasting glucose, which exerts a major influence over GD risk, supports the hypothesis that during pregnancy MBS also influences glycemic dynamics in a body weight independent manner.

Nevertheless, the so far available evidence on GD and MBS must be interpreted with caution, as the majority of the studies used a 75 g or 100 g OGTT for GD diagnosis [ 17 ], despite the known caveat of depicting altered glucose kinetics, with early hyperglycemia leading to an increased rate of false positive GD diagnoses [ 18 ]. Indeed, fasting glucose levels were previously shown to be lower in women after MBS when compared both to lean or BMI-matched controls, while the postprandial glucose excursion curve showed a characteristic pattern, including a glucose rise at 60 min followed by reactive hypoglycemia, which occurred in 54.8% of the cases [ 19 ]. Although there is no doubt that alternative GD diagnostic criteria are still needed for this specific population [ 18 ], in the meantime, frequent capillary blood glucose self-monitoring is the diagnostic resource most frequently used [ 20 ]. The fact that in our study GD screening relied on capillary blood glucose measurements further strengthens the finding of a reduced prevalence of GD after MBS, irrespectively of the weight loss achieved or GWG.

MBS was also associated with a higher prevalence of SGA and reduced newborn’s birth weight and height, despite there were no significant differences on GWG or time from surgery to conception. Despite the difficulties to differentiate a SGA from FGR fetus [ 21 ], the association between MBS and low birth weight, regardless of the matching performed, seems to be fairly unanimous [ 9 , 22 , 23 , 24 ]. Kwong et al. found that the risk of SGA in women after BMS was higher when compared to women matched for pre-surgery BMI, as well as, PC BMI with an odds ratio (OR) of 2.16 and an OR of 2.23, respectively [ 8 ]. In a subsequent study by Jacamon et al., MBS was associated with a reduced risk of excessive fetal growth with a trend for a higher incidence of SGA, despite matching on PC BMI [ 15 ]. Another study concluded that in singleton gestations, women with obesity who underwent a prior MBS, had a higher risk of FGR, which further supports the association of MBS with FGR, regardless the weight loss or BMI achieved [ 25 ]. The lack of essential nutrients in result of a combination of food restriction and malabsorption was hypothesized to be responsible for the negative impact on fetal growth [ 26 ]. A short surgery-to-conception interval and a GWG lower than recommended by the Institute of Medicine (IOM) are additional factors that may influence fetal growth after MBS [ 14 , 23 ]. Moreover, a greater glycemic variability, a lower glucose nadir during the OGTT and a greater incidence of postprandial hypoglycemia were also proposed to have a negative impact on the development of fetuses from women previously submitted to gastric bypass [ 27 ]. Nevertheless, detailed data on glucose kinetics during pregnancies after different BMS procedures are not currently available [ 19 ]. Continuous glucose monitoring during pregnancy after BMS could not only prove to be a valid alternative to diagnose GD, but also provide detailed information on glucose kinetics, most particularly the occurrence of asymptomatic hypoglycemic events, and how these impact on pregnancy outcomes [ 28 ]. Moreover, this data could be useful to guide clinicians and dieticians to provide targeted macronutrient intake counseling to avoid hypoglycemic events, potentially harmful to the fetus [ 29 ].

When managing pregnancy in women after MBS it is important to take into account several factors, obesity related or not, which may influence the obstetric outcomes [ 30 , 31 ]. Smoking is recognized to be a major risk factor for lower fetal weight, irrespective of mother’s surgical status [ 32 ]. After excluding smoking mothers from the pregnancies analysis, there was no longer a significant difference in SGA, although both fasting glucose mean and birth weight remained significantly lower.

Daily low-dose ASA is part of standard obstetric care to reduce the risk for preeclampsia, preterm birth, small for gestational age/intrauterine growth restriction, and perinatal mortality in pregnant women at high risk for preeclampsia [ 33 ]. Pregnant women submitted to MBS frequently fulfil criteria for ASA prescription (previous history of preeclampsia, BMI greater than 30, maternal age greater or equal to 35 years) [ 34 ]. As a consequence, the use of ASA was more prevalent in women submitted to surgery.

Maternal anemia during gestation and puerperium was also more frequent in pregnancies of women who had undergone MBS. In our study, less than half of the women previously submitted to MBS reported to adhere to vitamin supplement recommendations prior to conception, and more than one in ten women conceived within one year after the surgery despite medical counselling to postpone pregnancy plans until after the second postoperative year. Although these women were under regular follow-up with a multidisciplinary obesity team, it has been clearly shown that most patients either fail to perceive the potential benefits of vitamin supplementation compliance or have financial constraints, which render micronutrient deficiencies a frequent complication after MBS [ 11 ],

The main strengths of this study are the adjustment for two major variables for the outcomes being studied (age and PC BMI), the fact that PC BMI and not pre-surgery BMI was considered, and that all women were followed up at a single center by the same multidisciplinary team comprising obstetricians, endocrinologists and dietitians. The GD screening was performed by frequent capillary glucose self-monitoring; data on fasting glucose was included in the analysis, and the impact of smoking was considered on obstetrics outcomes. However, there are also limitations that must be acknowledged. First, the study retrospective design and small sample size are likely to have hindered the statistical significance of some parameters. Second, not all women underwent MBS at the same institution nor by the same surgical team. Third, given the small numbers, it was not possible to evaluate a potential influence of different types of MBS procedures on the study outcomes. Forth, it was not possible to evaluate to what extent the outcomes found were due to the PC BMI rather than residual from the pre-surgery BMI. Finally, although smoking arises as an important variable accounting for the occurrence of SGA, we were unable to disentangle the relative contribution of active vs inactive smoking due to lack of data.

Conclusions

MBS was associated with a prevalence of GD that was lower than observed in non-operated women with the same age and BMI. After controlling for smoking habits, this occurred at the expense of a lower birth weight but without criteria for SGA. Our data reinforces the hypothesis that MBS has body weight independent effects on glucose kinetics during pregnancy with potentially distinctive impacts for mother and offspring, which need to be balanced.

Bluher M. Obesity: global epidemiology and pathogenesis. Nat Rev Endocrinol. 2019;15(5):288–98.

Article   PubMed   Google Scholar  

Devlieger R, et al. Maternal obesity in Europe: where do we stand and how to move forward?: A scientific paper commissioned by the European Board and College of Obstetrics and Gynaecology (EBCOG). Eur J Obstet Gynecol Reprod Biol. 2016;201:203–8.

Catalano PM, Shankar K. Obesity and pregnancy: mechanisms of short term and long term adverse consequences for mother and child. BMJ. 2017;356:j1.

Article   PubMed   PubMed Central   Google Scholar  

Marchi J, et al. Risks associated with obesity in pregnancy, for the mother and baby: a systematic review of reviews. Obes Rev. 2015;16(8):621–38.

Article   CAS   PubMed   Google Scholar  

Harreiter J, et al. Management of Pregnant Women after Bariatric Surgery. J Obes. 2018;2018:4587064.

Parent B, et al. Bariatric Surgery in Women of Childbearing Age, Timing Between an Operation and Birth, and Associated Perinatal Complications. JAMA Surg. 2017;152(2):128–35.

Getahun D, et al. Perinatal outcomes after bariatric surgery. Am J Obstet Gynecol. 2022;226(1):121 e1-121 e16.

Kwong W, Tomlinson G, Feig DS. Maternal and neonatal outcomes after bariatric surgery; a systematic review and meta-analysis: do the benefits outweigh the risks? Am J Obstet Gynecol. 2018;218(6):573–80.

Yi XY, et al. A meta-analysis of maternal and fetal outcomes of pregnancy after bariatric surgery. Int J Gynaecol Obstet. 2015;130(1):3–9.

Shawe J, et al. Pregnancy after bariatric surgery: Consensus recommendations for periconception, antenatal and postnatal care. Obes Rev. 2019;20(11):1507–22.

Snoek KM, et al. The effects of bariatric surgery on periconception maternal health: a systematic review and meta-analysis. Hum Reprod Updat. 2021;27(6):1030–55.

Article   Google Scholar  

Sousa-Santos RF, et al. Development of a birthweight standard and comparison with currently used standards. What is a 10th centile? Eur J Obstet Gynecol Reprod Biol. 2016;206:184–93.

International Association of D, et al. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care. 2010;33(3):676–82.

Johansson K, et al. Outcomes of pregnancy after bariatric surgery. N Engl J Med. 2015;372(9):814–24.

Jacamon AS, et al. Outcomes of pregnancy after bariatric surgery: results of a French matched-cohort study. Surg Obes Relat Dis. 2020;16(9):1275–82.

Rozanska-Waledziak A, et al. The influence of bariatric surgery on pregnancy and perinatal outcomes-a case-control study. J Clin Med. 2020;9(5):1324.

Deleus E, et al. Glucose homeostasis, fetal growth and gestational diabetes mellitus in pregnancy after bariatric surgery: a scoping review. J Clin Med. 2020;9(9):2732.

Freitas C, et al. Effect of new criteria on the diagnosis of gestational diabetes in women submitted to gastric bypass. Surg Obes Relat Dis. 2014;10(6):1041–6.

Feichtinger M, et al. Altered glucose profiles and risk for hypoglycaemia during oral glucose tolerance testing in pregnancies after gastric bypass surgery. Diabetologia. 2017;60(1):153–7.

Benhalima K, et al. Screening and management of gestational diabetes mellitus after bariatric surgery. Nutrients. 2018;10(10):1479.

Lees CC, et al. ISUOG Practice Guidelines: diagnosis and management of small-for-gestational-age fetus and fetal growth restriction. Ultrasound Obstet Gynecol. 2020;56(2):298–312.

Galazis N, et al. Maternal and neonatal outcomes in women undergoing bariatric surgery: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2014;181:45–53.

Akhter Z, et al. Pregnancy after bariatric surgery and adverse perinatal outcomes: A systematic review and meta-analysis. PLoS Med. 2019;16(8):e1002866.

Al-Nimr RI, et al. Effects of Bariatric Surgery on Maternal and Infant Outcomes of Pregnancy-An Evidence Analysis Center Systematic Review. J Acad Nutr Diet. 2019;119(11):1921–43.

Parker MH, Berghella V, Nijjar JB. Bariatric surgery and associated adverse pregnancy outcomes among obese women. J Matern Fetal Neonatal Med. 2016;29(11):1747–50.

Kjaer MM, et al. The risk of adverse pregnancy outcome after bariatric surgery: a nationwide register-based matched cohort study. Am J Obstet Gynecol. 2013;208(6):464 e1-5.

Gobl CS, et al. Assessment of glucose regulation in pregnancy after gastric bypass surgery. Diabetologia. 2017;60(12):2504–13.

Stentebjerg LL, et al. Roux-en-Y Gastric Bypass Increases Glycemic Excursions During Pregnancy and Postpartum: A Prospective Cohort Study. Diabetes Care. 2023;46(3):502–10.

Burlina S, Dalfra MG, Lapolla A. Pregnancy after bariatric surgery: nutrition recommendations and glucose homeostasis: a point of view on unresolved questions. Nutrients. 2023;15(5):1244

Otang-Mbeng W, Otunola GA, Afolayan AJ. Lifestyle factors and co-morbidities associated with obesity and overweight in Nkonkobe Municipality of the Eastern Cape, South Africa. J Health Popul Nutr. 2017;36(1):22.

Gaillard R, et al. Risk factors and outcomes of maternal obesity and excessive weight gain during pregnancy. Obesity (Silver Spring). 2013;21(5):1046–55.

Abraham M, et al. A systematic review of maternal smoking during pregnancy and fetal measurements with meta-analysis. PLoS ONE. 2017;12(2):e0170946.

Davidson KW, et al. Aspirin use to prevent preeclampsia and related morbidity and mortality: US preventive services task force recommendation statement. JAMA. 2021;326(12):1186–91.

ACOG Committee Opinion No. 743: Low-Dose Aspirin Use During Pregnancy. Obstet Gynecol. 2018;132(1):e44–52.

Download references

Open access funding provided by FCT|FCCN (b-on). Unit for Multidisciplinary Research in Biomedicine (UMIB) is funded by the Foundation for Science and Technology (FCT) Portugal (UIDB/00215/2020 and UIDP/00215/ 2020). ITR is funded by FCT Portugal (LA/P/0064/2020).

Author information

Authors and affiliations.

Centro Materno-Infantil do Norte – Centro Hospitalar Universitário de Santo António (CMIN-CHUdSA), Porto, Portugal

Diana Rodrigues-Martins & Jorge Braga

Endocrine and Metabolic Research, UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal

Diana Rodrigues-Martins, Sara Andrade, Sofia S. Pereira & Mariana P. Monteiro

ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal

Obstetrics and Gynecology, Centro Hospitalar Vila Nova de Gaia/ Espinho, Porto, Portugal

CINTESIS - Centro de Investigação Em Tecnologias E Serviços de Saúde, University of Porto, Porto, Portugal

Institute of Biomedical Sciences Abel Salazar - University of Porto, Rua Jorge Viterbo Ferreira 228, Building 1.3, 4050-313, Porto, Portugal

Mariana P. Monteiro

You can also search for this author in PubMed   Google Scholar

Contributions

Diana Rodrigues-Martins – Conceptualization, data curation, methodology, investigation, writing – original draft.

Sara Andrade – Formal analysis, investigation, writing – review and editing

Sofia Pereira – Formal analysis, investigation, writing – review and editing

Jorge Braga - Methodology, investigation.

Inês Nunes - Methodology, investigation, writing – review and editing

Mariana P Monteiro – Conceptualization, methodology, writing – review and editing

Corresponding author

Correspondence to Mariana P. Monteiro .

Ethics declarations

Ethics approval.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study (no. 214–20 (167-DEFI/168-CE).

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

GD is less frequent and mean fasting glucose is lower in pregnancies after MBS.

MBS was associated with lower birth weight but not small-for-gestational-age fetuses.

MBS effect on pregnancy glucose kinetics seem to be body weight independent.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 16 KB)

Supplementary file2 (docx 16 kb), supplementary file3 (docx 18 kb), rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Rodrigues-Martins, D., Andrade, S., Pereira, S.S. et al. Gestational Diabetes Risk and Low Birth Weight After Metabolic Bariatric Surgery: a Complex Interplay to be Balanced. OBES SURG (2024). https://doi.org/10.1007/s11695-024-07314-1

Download citation

Received : 22 March 2024

Revised : 22 May 2024

Accepted : 23 May 2024

Published : 04 June 2024

DOI : https://doi.org/10.1007/s11695-024-07314-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Bariatric surgery
• Perinatal outcomes
• Find a journal
• Publish with us
• Track your research

Journal of Neurology, Neurosurgery and Psychiatry

is a leading international journal publishing the latest research and reviews on all areas of neurological sciences.

Impact Factor: 11.1 Citescore: 15.9 All metrics >>

Journal of Neurology, Neurosurgery and Psychiatry  is a  Plan S compliant Transformative Journal .

Journal of Neurology, Neurosurgery and Psychiatry (JNNP)'s ambition is to publish the most ground-breaking and cutting-edge research from around the world. Encompassing the entire genre of neurological sciences, our focus is on the common disorders (stroke, multiple sclerosis, Parkinson's disease, epilepsy, peripheral neuropathy, subarachnoid haemorrhage and neuropsychiatry), but with a keen interest in the Gordian knots that present themselves in the field, such as ALS. With early online publication, regular podcasts and an immense archive collection, JNNP is a trail-blazer and not a follower.

Subscribers to JNNP also have access to  Practical Neurology  and the  Journal of NeuroInterventional Surgery .

JNNP has a fully open access companion journal,  BMJ Neurology Open , publishing research in all areas of clinical neurology and neuroscience.

Editor in Chief:   Dr Karen Furie , Warren Alpert Medical School of Brown University Editorial Board

JNNP accepts submissions of a wide range of article types, including review articles and original research.

The Author Information section provides specific article requirements to help you turn your research into an article suitable for JNNP.

Information is also provided on editorial policies and open access .

Latest Articles

Editorial commentaries :

14 May 2024

Neuromuscular :

Cerebrovascular disease :

Most Read Articles

Movement disorders :

14 February 2024

General neurology :

14 September 2023

13 July 2023

Neuropsychiatry :

15 November 2023

13 March 2024

Related Journals

BMJ Neurology Open

General Psychiatry

Journal of NeuroInterventional Surgery

Practical Neurology

Stroke and Vascular Neurology

Weight Loss Surgery Misunderstood by Most Americans

Most Americans are wrong about surgical treatments for obesity, medical professionals have warned.

That assessment comes after a nationally representative survey of U.S. adults found that so-called bariatric surgery is often seen as a "shortcut" to weight loss—and something that should be used only as a last resort.

In contrast, doctors say that such operations are needed to reduce obesity-related medical problems and help patients live healthier lives.

More than two in five U.S. adults live with obesity—and one in 11 has severe obesity—with both figures on the rise, according to the National Institutes of Health.

Bariatric surgeries represent an extremely effective treatment option for obesity. However, researchers fear that the stigma created by popular perceptions of the procedures may be putting people off from pursuing the treatment they need.

While millions of Americans are eligible for these operations, only around 250,000 are performed in the U.S. each year.

Bariatric surgery involves making changes to the digestive system to help the person lose weight—either by limiting how much one can eat, the number of calories and how much fat the body can absorb, or both.

While typically effective, the procedures need to be followed by permanent changes to the person's diet and an exercise regime to ensure long-term success.

"Patients can generally expect to lose 70–80 percent of their excess weight in the first 6–12 months after surgery, and on average they maintain approximately 50 percent excess weight loss in the long term," Dr. Kamal Mahawar, a bariatric surgeon with the Sunderland Royal Hospital in England, told Newsweek .

He added: "In addition, they can expect a significant improvement—and even resolution in a large proportion—in a number of obesity-associated health conditions such as type 2 diabetes, high blood pressure, sleep apnea, fatty liver, etc.

"It is a highly cost-effective health intervention. Bariatric surgery adds years to life and life to years!"

Two of the most common types of bariatric surgery are a gastric bypass, in which the top part of the stomach is isolated from the rest, and a sleeve gastrectomy, in which 80 percent of the stomach is removed.

All these surgeries are major operations that can come with risks and side effects. According to Dr. Mahawar, these include an approximate 30-day mortality of 1:1,000, an overall complication risk of 7–8 percent and a major complication risk of 1–2 percent.

However, developments in exploratory and robotic surgery in recent years have made bariatric surgeries both safer and less invasive than ever before—and among the most commonly performed operations in general surgery.

Accordingly, health professionals with the American Society for Metabolic and Bariatric Surgery and the International Federation for the Surgery of Obesity and Metabolic Disorders recently revised their guidelines, making bariatric surgery accessible to a larger number of patients.

Under the new recommendations, patients are eligible for bariatric surgery if they have a body mass index (BMI) of 30 and above with an accompanying condition such as high blood pressure or type 2 diabetes, or 35 and above without.

However, it is estimated that only around 1 percent of those who are clinically eligible for these surgical procedures actually undergo them.

Dr. Andre Teixeira is a surgeon at the Orlando Health Weight Loss and Bariatric Surgery Institute in Florida. Reacting to the survey finding that 60 percent of U.S. adults believe that surgery is a shortcut to weight loss, he told Newsweek : "There is a misconception that it's the easy way out for weight loss—but in reality, it's the opposite.

"Also, bariatric surgery is seen, sometimes, as a cosmetic procedure, but that is so far from the truth. Bariatric surgery is related to the cure or improvement of metabolic disease, and the obesity itself.

He continued: "If you have the courage to ask for help and commit to doing the hard work of changing your diet and improving your life, you're a champion in my book."

An operation is simply a tool to jump-start that kind of change, Teixeira pointed out. "After surgery, it is up to the patient to learn how to eat well, implement exercise into their routine and shift their mindset to maintain their health for the rest of their lives," he said.

"People who choose to have a bariatric procedure are not weak," professor Wendy Brown—a bariatric surgeon from Australia's Monash University, who was not involved in the research—told Newsweek .

She continued: "They are brave. They are recognizing they have an opportunity to improve their health and well being by losing weight and are willing to take steps to overcome the powerful physiology that so often works against them.

"We need to engender empathy for the difficulty people living with obesity face."

However, the survey of 1,017 U.S. adults, which was conducted for Orlando Health by polling company Ipsos, found that 61 percent of respondents don't approve of surgical treatments in the first place and think that people should lose weight using diet and exercise alone.

Similarly, 79 percent of those surveyed said that they felt weight loss surgeries should be pursued only as a last resort.

"Because of the stigma around obesity and bariatric surgery, so many of my patients feel defeated if they can't lose weight on their own," said Dr. Muhammad Ghanem, another bariatric surgeon at the Orlando Health Weight Loss and Bariatric Surgery Institute, according to a statement.

"But when I tell them obesity is a disease and that many of its causes are outside their control, you can see their relief. They often even shed a tear because they've struggled with their weight all their lives and finally have some validation," he said.

Professor Yitka Graham is a researcher with the University of Sunderland whose work focuses on the experiences of people living with obesity, and who undergo bariatric surgery.

She told Newsweek : "Society is not kind to people living with obesity. It is often seen as a moral failing—that people are to blame for their excess weight, despite strong evidence to show that obesity is a complex condition, with environmental, societal, biological and genetic factors at play.

"Moreover, a reductionist calculation of 'eat less, exercise more', is often applied to people living with excess weight, which does not account for the complexity of obesity, and often does not work.

"Society needs to examine its unconscious biases towards obesity and bariatric surgery, and accept that bariatric surgical intervention is an effective method of weight-loss and disease improvement, which is fundamentally life-changing and life-saving for the people who undergo these procedures."

As Graham notes, the stigma around bariatric surgery also discourages many who have undergone these procedures from talking about it openly, and challenging misconceptions.

For example, one patient Graham interviewed in her research—a woman, 48, who lost five stone after a gastric bypass—related the following incident: "I was out with colleagues for a work dinner, and one turned to me and said: 'I know you've had one of those silly stomach stapling operations'.

"I said I hadn't, and she said: 'If I find out you have, I will never speak to you again."

"Bariatric surgery is an effective treatment for people with severe and complex obesity, but is definitely not an easy option, as anyone who has undergone one of these procedures will tell you," Dr. Karen Coulman, an obesity specialist dietitian at the University of Bristol, told Newsweek .

She explained that, after bariatric surgery, individuals require long-term support from health professionals to minimize side-effects like nutritional deficiencies, as well as to support their physical and psychological health.

Coulman added: "Bariatric surgery should in no way be seen as a "shortcut" to weight loss. People seeking bariatric surgery have been trying 'diet and exercise alone' for years and many feel that bariatric surgery is their last resort."

"Obesity is a medical condition like any other and seeking treatment should be commended, it's a fantastic initiative patients are taking to improve their health," Dr. Dan Azagury, a bariatric surgeon with Stanford Health Care, told Newsweek .

He added: "Bariatric surgery is the most effective treatment for obesity, but it's the opposite of a shortcut! It's simply a tool to turn the odds around."

In fact, Azagury explains, in the long-term diet and exercise have a failure rate greater than 90 percent for weight loss.

"The surgery provides [patients] with a tool to go from an 80–90 percent failure rate to an 80–90 percent success rate," he continued, noting that rather than being an unfair shortcut, bariatric procedures can serve to level the playing field for people whose metabolism is unfairly working against them.

Patients, he added, "still have to implement the changes in the long run. It is a battle they fight every single day, to keep the weight off.

"The surgery only turns the fight into one they actually have a chance to win."

Case Study: Maritza Cruz Rivera, 64 Cruz Rivera said that after suffering from fatigue and pain for years, the final straw came during a regular checkup with her primary care physician. "When they weighed me before my appointment, I looked at the scale and started to cry. There it was: 227," she said. "Something triggered in me in that moment to finally do something about my weight and get some help." Even though Cruz Rivera was supported by many of her friends and family in her decision to get bariatric surgery—after being told it was a good option for her by a doctor—she also encountered a lot of misconceptions about such procedures. She said that people considering bariatric surgery should make their decision based on what's best for their health and get the proper facts from a medical professional. A year after her procedure—and aided by a more healthy relationship with food—Cruz Rivera is at a healthy weight and enjoying life. Her days now include going for long walks, riding a bicycle with her grandchildren and a much-loved pastime: dancing. "I haven't been able to dance like this in 20 years. I didn't go into this to look like Barbie. I just wanted to live a healthy life with my family, and now I can do that," she said. "For anyone struggling with obesity who feels depressed or stuck like I did, don't bury yourself in that dark hole. Understand and know that there's always a solution."

Speaking about how he tailors weight loss plans for specific patients, Teixeira said factors that are accounted for include body mass index and existing medical conditions.

The treatment programs, he added, can end up including bariatric surgery, counseling, lifestyle changes and medication.

"By taking this personalized approach, we are extremely successful in reversing health issues caused by obesity, from diabetes to heart disease," he said.

"But if someone's decision is affected by those who think they don't need surgery—or that make them feel like a failure if they have surgery—that greatly diminishes their chances of losing weight and maintaining a healthy lifestyle long term," Teixeira said.

Update 11/01/24, 13:08 p.m. ET: This article was updated to include comment from Drs. Azagury and Coulman.

Related Articles

• Scientists Reveal Which Low-Carb Diets Work Best for Weight Loss
• US Physical Inactivity Has Become 'a Crisis Within a Crisis'
• Vibrating Pigs Pave the Way to New Obesity Treatment
• Going Vegan May Lower Your Cholesterol, Insulin and Weight—Study
• Depression May Cause Weight Gain for Some People, Study Finds
• Gastroenterologists Reveal Breakfast They Eat for Healthy Gut

Start your unlimited Newsweek trial