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I'm going to be frank: I am more than just XXL, I am very obese. According to the doctor, my BMI is 50. At the same time, I do work out to stay healthy (I don't think I'll ever really lose the weight). But I need a shoulder replacement. Can fat people like me handle joint replacement?

You raise a very good question and one that many people may be facing as the number of adults who are obese increases in the coming years. There are some special considerations when someone with a body mass index (BMI) of 50 thinks about having joint replacement surgery. For example, many people (children/teens and adults) who have a BMI greater than 30 also have other health concerns. Diabetes is the number one health risk factor. Diabetes increases the risk of poor wound healing and infection. Traditional anatomic total shoulder replacements have been shown to aid in reducing pain and improving motion and function in very obese patients. But when compared with adults who are not obese (and who also receive an anatomic total shoulder replacement), results are definitely not as good. The obese patient is more likely to have problems and complications and less likely to be happy with the results. The "normal" or anatomic shoulder replacement was designed to copy our real shoulder. The glenoid component (the socket) was designed to replace our anatomic shoulder socket with a thin, shallow plastic cup. The humeral head component was designed to replace the ball of the humerus with a metal ball that sits on top of the glenoid. A different type of implant has been developed for use with older adults who need a shoulder replacement but who have a severe tear of the rotator cuff tendons. The four muscles and their tendons that make up the rotator cuff fit around the shoulder joint and help hold the joint stable yet provide full range-of-motion at the same time. This alternate replacement device is called a reverse total shoulder arthroplasty (RTSA). Without an intact rotator cuff, the implant often loosens and/or the shoulder dislocates. This can be prevented by reversing the socket and the ball, placing the ball portion of the shoulder where the socket used to be and the socket where the ball or humeral head used to be. This new design provides a much more stable shoulder joint that can function without a rotator cuff. How well does it work with people who have an intact rotator cuff but have a different problem: they are obese. To find out, the reverse total shoulder arthroplasty (RTSA) was used in three separate groups and results compared in a recent study. The three groups included 17 obese patients, 36 patients who are overweight, and 23 patients in the normal weight category. Patients ranged in age from 51 to 88 years old. They found that obese patients were able to regain significant amounts of lost motion but they also had significantly more complications than the other two groups. The obese patients lost more blood during the procedure, but surgical time and length of hospital stay were the same among all three groups. Complications were greater in the obese group for several reasons. Surgical difficulties occur just due to the amount of adipose tissue (fat) that must be cut through to get to the shoulder joint. Fatty tissues tend to have less blood flow to them (they are said to be poorly vascularized). This lack of blood flow can delay or impair healing. Many more patients in the obese group also had diabetes, which we already know is a risk factor in delayed wound healing. And the infection rate of 18 per cent in the obese group was clearly much higher than for the nonobese group who had no (zero per cent) infections. Although obesity is NOT a contraindication to reverse total shoulder replacement, patients should be aware of the high complication rate, especially for the risk of infection. Of course, you can also expect the same improvements in motion and reductions in pain obtained by nonobese patients. Time will tell if other changes (positive or negative) will occur in the long-term results. Your primary care physician working in conjunction with your orthopedic surgeon will evaluate your case and advise you as to the best treatment approach to your shoulder problem. So before crossing yourself off the treatment list, seek counsel from these experts and find out what are all of your options. And good luck!

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