GLP-1 medications are doing something orthopedic surgeons have not seen: returning patients to the surgical candidate pool.
Patients who were previously excluded from joint replacement because of weight or uncontrolled diabetes are now reaching the BMI thresholds and metabolic benchmarks that make surgery viable — and some are losing enough weight that surgery can wait.
However, as the surgical candidate pool expands, a problem is following patients in. Rapid weight loss strips muscle along with fat, and muscle is what gets patients through rehabilitation. GLP-1 therapy without structured nutrition and strength training produces a thinner patient, but not necessarily a better surgical candidate.
Ask Orthopedic Surgeons is a series of questions posed to orthopedic surgeons and leaders around the country about clinical, business and policy issues affecting orthopedic care. Becker’s invites all orthopedic surgeons and specialists to respond.
Next question: Where do you think the orthopedic industry is being dishonest with itself right now?
Please send responses to Cameron Cortigiano at ccortigiano@beckershealthcare.com by 5 p.m. Central time Oct. 19.
Note: Responses were lightly edited for clarity and length.
Question: How is the GLP-1 boom affecting your orthopedic patient population, for better or worse?
Evalina Burger, MD. Chair of the Department of Orthopedics at the University of Colorado Anschutz (Aurora): Access to GLP-1 medications remains limited in many areas due to insurance restrictions. Patients who are able to access them have had remarkable results. They are more motivated and perform better in the rehab phase.
Jeffrey Carlson, MD. Orthopedic Spine Surgeon and President of Orthopaedic & Spine Center (Newport News, Va.): GLP-1s have been a great advancement in treating diabetes and obesity. In the past several years, as more patients have started treatment with GLP-1s, we have seen an improvement in the health of our patients. Most orthopedists are limiting their patients by BMI and HgA1C, which has placed many patients in a difficult situation. Patients with obesity or difficulty controlling diabetes are not candidates for surgery to fix the painful knee, hip or spine that contributes to their obesity and diabetes control issues. The addition of GLP-1s has opened a new pathway for patients to get their diabetes under control and decrease their weight, which makes them fit into the parameters needed to have the most successful outcome. After surgery, these patients can now exercise to help maintain their weight and blood sugars. GLP-1s have made a big difference in their lives.
Andrew Harris, MD. Orthopedic Surgeon at Endeavor Health Orthopaedic & Spine Institute (Chicago): Mostly for the better. A lot of patients who were told they needed to lose weight before joint replacement are now reaching that goal, and being at a healthy weight lowers the risk of complications after hip and knee replacement. The concern is how fast some patients may lose weight. Rapid weight loss can come with muscle loss and poor nutrition, and those patients often recover more slowly after surgery. We screen for this before surgery, and we work with patients and their primary care physicians on protein intake and strength, so they arrive at surgery ready to recover. We also hold GLP-1 medications before surgery because of anesthesia-related risk.
Andrew Hsu, MD. Orthopedic Surgeon at UCI Health (Irvine, Calif.): From the perspective of an orthopedic foot and ankle surgeon, increased use of GLP-1 medications has had a significantly positive impact on my patients with diabetes, obesity and metabolic disease who historically have been at high risk for post-surgical complications. By facilitating weight loss, GLP-1 therapy has also helped my patients prolong nonoperative treatments by reducing mechanical stress across the foot and ankle and improving mobility and function. In surgical patients, GLP-1 medications can decrease several modifiable risk factors for wound complications, infection and impaired bone healing by improving glycemic and metabolic control. Recent literature has shown lower rates of nonunion following certain hindfoot, ankle and first MTP fusions in GLP-1 users, especially among patients with diabetes, with additional results reporting reductions in surgical-site infection, revision surgery and other complications. In my practice, GLP-1 medications have been a helpful tool to optimize metabolic function before surgery, thus helping transform higher-risk patients into better surgical candidates and improving overall outcomes.
Amit Jain, MD. Spine Surgeon and Vice President of Care Transformation at Johns Hopkins Medicine (Baltimore): In general, it has been positive for the patients needing spinal surgery. Weight loss is an important component of preoperative optimization for obese patients. Of course, this must be balanced against sarcopenic muscle loss and delayed gastric emptying.
Jaclyn Jankowski, DO. Orthopedic Surgeon at RWJBarnabas Health Medical Group (West Orange, N.J.): From an arthritis standpoint, GLP-1s have seemed to have a net positive effect for my patients. In patients with earlier stages of arthritis, weight loss can decrease the load placed on and forces applied to the joints of the lower extremity, leading to a reduction of pain and an improvement in function. In patients with end-stage arthritis, these medications are helping some who were not previously considered candidates for surgery to now be candidates for joint replacement (as in now they are meeting the BMI thresholds and improving their overall metabolic health, allowing them to be better optimized for surgery from a medical comorbidity standpoint). It is, however, very important that we are made aware when patients are taking these medications because they do need to be held prior to surgery, and if they are not stopped within the necessary timeline, surgery will be canceled. Additionally, making sure that one is maintaining appropriate nutrition and protein intake while on these medications is very important for the sake of wound healing postoperatively.
Farzin Kabaei, MD. Orthopedic Surgeon at Docs Health (Los Angeles): Mostly for the better. Patients who could not get to a safe weight for a hip or knee replacement are now getting there, and a lighter patient is a safer operation and an easier recovery. Some lose enough weight that their joint pain improves and surgery can wait. The downside is muscle. Patients who lose weight fast without strength training and enough protein lose muscle along with the fat, and muscle is what gets you through rehab. I tell my patients the medication is the start, not the plan. We also have to coordinate these drugs carefully around anesthesia. A GLP-1 without a trainer and a nutrition plan gives me a thinner patient, not a stronger one.
Jeffery Kannen, DO. Orthopedic Surgeon at Florida Orthopaedic Institute (Tampa): The widespread use of GLP-1 offers challenges to orthopedic care. While these treatments can improve the metabolic health of patients taking them for diabetes and weight loss, there can be negative unintended effects such as loss of lean muscle mass and a decrease in bone density. This can lead to physical deconditioning and fragility fractures in higher-risk patients. Patients should be counseled on these risks and, if appropriate, should obtain a screening bone density test to assess bone quality prior to treatment with GLP-1.
Adam Rivadeneyra, MD. Sports Medicine Physician with Hoag Orthopedic Institute (Newport Beach, Calif.): GLP-1 medications are a great tool for blood sugar control, weight loss and even some pain relief in patients with arthritis. In orthopedics, we see a lot of benefit in function and pain control. We have some concerns as well due to side effects. For patients having orthopedic surgeries, they need to stop the medications before surgery to allow their digestive system to work more normally and reduce anesthesia complications. We also see a lot of muscle loss in patients losing weight, which can be a big problem with weakness, disability, falls and difficulty recovering from injury or surgery. I always recommend patients use GLP-1 medications under direct medical supervision, prioritize strength training and increase the amount of protein in their diets to reduce risk of complications.
Robert Runner, MD. Orthopedic Surgeon at All-Star Orthopedics (Dallas): In my practice, I’m seeing GLP-1 medications have a positive impact on many of my orthopedic patients. Weight loss can decrease the forces across the hip and knee joints, and some patients experience enough improvement in their pain and function to delay or, in some cases, avoid joint replacement surgery. For patients who do need surgery, getting to a healthier weight and improving their overall health before surgery can be very beneficial, and emerging evidence suggests that patients taking GLP-1 medications can have favorable outcomes following joint replacement, although the long-term effects are still being studied. At the same time, I pay close attention to nutritional optimization and muscle mass, particularly before surgery, because rapid weight loss can sometimes be accompanied by inadequate protein and nutrient intake. Overall, I think GLP-1 medications are becoming more widespread and can be another valuable tool in helping patients get healthier and get the most out of their orthopedic care.
Joseph Zuckerman, MD. Chair of the Department of Orthopedic Surgery at NYU Langone Health (New York City): There has been no noticeable impact as of yet, other than the need for changes in perioperative management.
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