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Weight, Obesity and Joint Health

How body weight and obesity affect joint load, osteoarthritis, and the risks and outcomes of joint surgery — including the role of weight loss before an operation.

Overview

Obesity represents a systemic disease with profound inflammatory consequences on joint health, extending beyond mechanical burden [5]. Despite these complexities, body mass index (BMI) should not serve as an exclusion criterion for primary total joint arthroplasty at ambulatory surgical centers [2]. Focusing on the management of preoperative comorbidities and custom surgical planning achieves outcomes comparable to those of patients with normal BMIs [2]. A BMI greater than 40 is not correlated with early complications in this setting [2], and a BMI of 45 serves as a safe cut-off for cementless total knee arthroplasty, although sample sizes for BMI ≥45 remain too small to draw definitive conclusions [3]. Ten-year functional outcomes and revision rates do not justify restricting access to surgery based on BMI [28].

In specific joint contexts, obesity severity does not predict adverse surgical trajectories. Increasing obesity severity is not associated with higher rates of postoperative stiffness following total knee arthroplasty or inferior outcomes after manipulation under anesthesia [6]. Concern for stiffness alone should not serve as a categorical barrier to these interventions when clinically indicated [6]. Similarly, BMI does not affect clinical outcomes following arthroscopically assisted posterior latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears, with no significant differences observed between above-average and below-average BMI groups [4]. In hip arthroplasty, obesity class does not associate with the incidence, timing, or invasiveness of reoperations [7].

Conversely, obese and overweight patients convert to total hip arthroplasty at significantly higher rates than normal-weight patients following hip arthroscopy for femoroacetabular impingement syndrome [12]. Regarding total knee arthroplasty, the current body of literature regarding tibial stem extension in obese patients is limited and heterogeneous, creating uncertainty rather than proving inefficacy [1]. Current evidence does not support the routine use of tibial stem extensions due to insufficient, heterogeneous, and very low certainty data [8], though specific implant designs may benefit selected populations [8]. Future multicenter studies with standardized implant designs, consistent BMI stratification, and at least 10 years of follow-up are needed before definitive conclusions can be drawn [1].

How It Works

Obesity is a systemic disease with profound inflammatory consequences on joint health, extending beyond its role as a mechanical burden on the knee [5]. High body mass index elevates the risk of both knee and hand osteoarthritis irrespective of metabolic status [23]. The increased risk of knee osteoarthritis attributed to high BMI is more evident in metabolically healthy participants [23]. Following medial meniscus posterior root tear repair, osteoarthritis progression occurs with higher rates seen with elevated body mass index [20]. Obesity and preexisting osteoarthritis are known risk factors for predicting poor outcomes and conversion to arthroplasty after knee arthroscopy [15].

Peri-incisional Adiposity: Body mass index has a weak-to-moderate association with peri-incisional adiposity in primary total joint arthroplasty patients [11]. Body mass index is not an appropriate proxy for the condition of peri-incisional adiposity in primary total joint arthroplasty patients [11]. The soft tissue-to-bone ratio reflects local anatomical factors that directly influence surgical exposure and wound healing, outperforming body mass index in predicting periprosthetic joint infection in total knee arthroplasty [19].

Comorbidity Management: Type 2 diabetes is not an independent risk factor for reoperation when adjusted for body mass index in obese patients undergoing total hip arthroplasty [14]. Type 2 diabetes is not associated with excess risk of periprosthetic joint infection in obese patients undergoing total hip arthroplasty [14]. Focusing on management of preoperative comorbidities and custom surgical planning can achieve outcomes comparable to those of patients with normal body mass index at ambulatory surgical centers, questioning body mass index as an exclusion criterion [2]. Body mass index greater than 40 is not correlated with early complications in patients undergoing primary total joint arthroplasty at an ambulatory surgical center [2].

Arthroplasty Outcomes: Body mass index of 45 is a safe cut-off for cementless total knee arthroplasty, although the numbers were too small to draw conclusions in patients with a body mass index greater than or equal to 45 [3]. Increasing obesity severity is not associated with higher rates of postoperative stiffness or inferior outcomes following manipulation under anesthesia after total knee arthroplasty [6]. Concern for stiffness alone should not serve as a categorical barrier to total knee arthroplasty or manipulation under anesthesia when clinically indicated [6]. The World Health Organization obesity class is not associated with risk, invasiveness, or timing of reoperations after total hip arthroplasty [7]. Modern surgical practices and implant designs may have mitigated traditional obesity-related risks, showing minimal impact on loosening and mechanical failure in total knee arthroplasty [9].

Robotic-Assisted Arthroplasty: High body mass index is associated with comparable functional outcomes but higher mechanical failures in functionally aligned image-based robotic total knee arthroplasty [13]. Obesity remains a critical risk factor for mechanical failures in functionally aligned image-based robotic total knee arthroplasty [13]. A nonsignificant trend toward a higher complication rate was observed in patients with severe obesity (body mass index greater than or equal to 35 kg/m2) in robotic-assisted total knee arthroplasty [21]. A statistically significant increase in arthrofibrosis was found in patients with a body mass index less than 25 kg/m2 in robotic-assisted total knee arthroplasty [21].

Other Surgical Contexts: Obesity had a negative influence on lower extremity long bone fracture in-hospital outcomes in pediatric patients [10]. Body mass index does not affect clinical outcomes following arthroscopically assisted posterior latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears [4]. No significant differences were observed between above-average and below-average body mass index groups in clinical improvements after arthroscopically assisted posterior latissimus dorsi tendon transfer [4]. Body mass index was not correlated with clinical improvements after arthroscopically assisted posterior latissimus dorsi tendon transfer [4].

Pharmacologic and Implant Considerations: Findings support a body mass index-based approach to perioperative semaglutide use, particularly in patients with a body mass index greater than 30 [22]. The current body of literature on tibial stem extension in total knee arthroplasty of obese patients is limited and heterogeneous, creating uncertainty rather than proving inefficacy [1]. Future multicenter studies with standardized implant designs, consistent body mass index stratification, and at least 10 years of follow-up are needed before definitive conclusions can be drawn regarding tibial stem extension in total knee arthroplasty of obese patients [1].

What the Evidence Shows

Tibial Stem Extension in TKA: Current literature on tibial stem extension in total knee arthroplasty for obese patients is limited and heterogeneous, creating uncertainty rather than proving inefficacy [1]. Current evidence does not support the routine use of tibial stem extensions in obese total knee arthroplasty patients due to insufficient, heterogeneous, and very low certainty data [8]. Specific tibial stem extension designs may benefit selected populations despite the lack of broad evidence support [8]. Future studies on tibial stem extension in total knee arthroplasty for obese patients require standardized implant designs, consistent BMI stratification, and at least 10 years of follow-up [1].

BMI as an Exclusion Criterion: Body mass index greater than 40 is not correlated with early complications in patients undergoing primary total joint arthroplasty at an ambulatory surgical center [2]. Management of preoperative comorbidities and custom surgical planning can achieve outcomes comparable to those of patients with normal BMIs at ambulatory surgical centers [2]. BMI should not serve as categorical exclusion criterion for primary total joint arthroplasty at ambulatory surgical centers [2]. A body mass index of 45 is a safe cut-off for cementless total knee arthroplasty, though sample sizes were too small to draw conclusions for patients with BMI greater than or equal to 45 [3].

Obesity and Joint Pathology Outcomes: Obesity is a systemic disease with profound inflammatory consequences on joint health, extending beyond its role as a mechanical burden on the knee [5]. Increasing obesity severity is not associated with higher rates of postoperative stiffness or inferior outcomes following manipulation under anesthesia after total knee arthroplasty [6]. Concern for stiffness alone should not serve as a categorical barrier to total knee arthroplasty or manipulation under anesthesia when clinically indicated [6]. Body mass index does not affect clinical outcomes following arthroscopically assisted posterior latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears [4]. No significant differences were observed between above-average and below-average BMI groups in outcomes for arthroscopically assisted posterior latissimus dorsi tendon transfer [4]. Body mass index was not correlated with clinical improvements in patients undergoing arthroscopically assisted posterior latissimus dorsi tendon transfer [4].

Implant Survivorship and Mechanical Failure: Obesity class does not associate with the incidence, timing, or invasiveness of reoperations after total hip arthroplasty [7]. Modern surgical practices and implant designs may have mitigated traditional obesity-related risks for loosening and mechanical failure in total knee arthroplasty [9]. High body mass index is associated with comparable functional outcomes but higher mechanical failures in functionally aligned image-based robotic total knee arthroplasty [13]. Obesity remains a critical risk factor for mechanical failures in functionally aligned image-based robotic total knee arthroplasty [13]. Obese patients are at increased risk of higher rates of revision following unicompartmental knee arthroplasty [18]. Dual mobility implants demonstrated excellent five-year survivorship with outcomes comparable or slightly superior to fixed-bearing constructs in morbidly obese patients undergoing primary total hip arthroplasty [24].

Comorbidities and Perioperative Risk: Type 2 diabetes is not an independent risk factor for reoperation when adjusted for BMI in obese patients undergoing total hip arthroplasty [14]. Type 2 diabetes is not associated with excess risk of periprosthetic joint infection in obese patients undergoing total hip arthroplasty [14]. Elevated body mass index is associated with weak-to-moderate increases in thromboembolic risk after total shoulder arthroplasty [29]. Elevated body mass index is not associated with increased infection or revision surgery risk after total shoulder arthroplasty [29]. Obesity increases the risk of all-cause revisions and revision for instability or dislocation in patients receiving reverse total shoulder arthroplasty indicated for fractures [16]. Body mass index has a weak-to-moderate association with peri-incisional adiposity in primary total joint arthroplasty patients [11]. Body mass index is not an appropriate proxy for the condition of peri-incisional adiposity in primary total joint arthroplasty patients [11].

Arthroscopy and Conversion to Arthroplasty: Obese and overweight patients converted to total hip arthroplasty at significantly higher rates compared with normal-weight patients following hip arthroscopy for femoroacetabular impingement syndrome [12]. Hip arthroscopy for femoroacetabular impingement and labral tears in patients with obesity yielded significant and sustainable long-term improvements equivalent to those of normal-weight patients [25]. Obesity and preexisting osteoarthritis are known risk factors for predicting poor outcomes and conversion to arthroplasty after knee arthroscopy [15]. Studies linking obesity and osteoarthritis to conversion after knee arthroscopy often lack control groups and specific procedural details to determine if surgery itself drives progression versus patient factors [15].

Weight Management Strategies: Semaglutide appears to be a safe alternative to bariatric surgery for weight management before total hip arthroplasty, with similar implant survival and postoperative complication rates [17]. Total weight loss percentage was higher in bariatric surgery patients compared to immediate total knee arthroplasty patients among those with severe obesity and advanced knee osteoarthritis [26]. Modern hip arthroscopy patients demonstrate improved patient-reported symptoms at the time of surgery, a decrease in mean patient BMI, and an increase in symptom duration reported prior to surgery [27]. Obesity had a negative influence on lower extremity long bone fracture in-hospital outcomes in pediatric patients [10].

Practical Considerations

Implant Selection and Design: Current literature on tibial stem extension in total knee arthroplasty (TKA) for obese patients is limited and heterogeneous, creating uncertainty rather than proving inefficacy [1]. Current evidence does not support the routine use of tibial stem extensions in obese TKA patients due to insufficient, heterogeneous, and very low certainty data [8]. Specific tibial stem extension designs may benefit selected populations despite the lack of broad evidence support [8]. Modern surgical practices and implant designs may have mitigated traditional obesity-related risks of loosening and mechanical failure in total knee arthroplasty [9]. Future studies on tibial stem extension in obese TKA patients require standardized implant designs, consistent BMI stratification, and at least 10 years of follow-up [1].

BMI as a Selection Criterion: Body mass index greater than 40 is not correlated with early complications in patients undergoing primary total joint arthroplasty at an ambulatory surgical center [2]. Management of preoperative comorbidities and custom surgical planning can achieve outcomes comparable to those of patients with normal BMIs at ambulatory surgical centers [2]. BMI should not serve as an exclusion criterion for primary total joint arthroplasty at ambulatory surgical centers; inclusive, evidence-based patient selection is advocated [2]. A body mass index of 45 is a safe cut-off for cementless total knee arthroplasty [3]. The number of patients with a BMI greater than or equal to 45 was too small to draw conclusions regarding cementless total knee arthroplasty outcomes [3]. Body mass index has a weak-to-moderate association with peri-incisional adiposity in primary total joint arthroplasty patients and is not an appropriate proxy for this condition [11].

Procedure-Specific Outcomes: Body mass index does not affect clinical outcomes following arthroscopically assisted posterior latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears [4]. No significant differences were observed between above-average and below-average BMI groups in clinical improvements after arthroscopically assisted posterior latissimus dorsi tendon transfer [4]. WHO obesity class does not associate with the incidence, timing, or invasiveness of reoperations after total hip arthroplasty [7]. Obesity is associated with an increased risk of all-cause revisions and revision for instability or dislocation in patients receiving reverse total shoulder arthroplasty indicated for fractures [16]. Obese patients are at increased risk of higher rates of revision following unicompartmental knee arthroplasty [18]. Obese and overweight patients converted to total hip arthroplasty at significantly higher rates compared with normal-weight patients after hip arthroscopy for femoroacetabular impingement syndrome [12].

Postoperative Management and Complications: Obesity is a systemic disease with profound inflammatory consequences on joint health, extending beyond its role as a mechanical burden on the knee [5]. Increasing obesity severity is not associated with higher rates of postoperative stiffness or inferior outcomes following manipulation under anesthesia after total knee arthroplasty [6]. Concern for stiffness alone should not serve as a categorical barrier to total knee arthroplasty or manipulation under anesthesia when clinically indicated [6]. Obesity has a negative influence on lower extremity long bone fracture in-hospital outcomes in pediatric patients [10].

Preoperative Optimization: Semaglutide appears to be a safe alternative to bariatric surgery for weight management before total hip arthroplasty [17]. Semaglutide and bariatric surgery show similar implant survival and postoperative complication rates for patients undergoing total hip arthroplasty [17].

Key Evidence

  • [L5] The current body of literature is limited and heterogeneous, creating uncertainty rather than proving inefficacy; future multicenter studies with standardized implant designs, consistent BMI stratification, and at least 10 years of follow-up are needed before definitive conclusions can be drawn. (10.1016/j.arth.2025.11.047)
  • [L3] Focusing on management of preoperative comorbidities and custom surgical planning can achieve outcomes comparable to those of patients who have normal BMIs at ASCs, questioning BMI as an exclusion criterion and advocating for more inclusive, evidence-based patient selection. (10.1016/j.arth.2025.08.065)
  • [L3] However, the numbers were too small to draw conclusions in patients who have a BMI ≥ 45. (10.1016/j.arth.2025.12.038)
  • [L2] No significant differences were observed between above-average and below-average BMI groups, and BMI was not correlated with clinical improvements. (10.1016/j.xrrt.2025.100634)
  • [L5] Obesity is more than a mechanical burden on the knee; it is a systemic disease with profound inflammatory consequences on joint health. (10.1002/arj.70051)
  • [L3] These findings suggest that increasing obesity severity is not associated with higher rates of postoperative stiffness or inferior outcomes following MUA and that concern for stiffness alone should not serve as a categorical barrier to TKA or MUA when clinically indicated. (10.1016/j.arth.2026.03.080)
  • [L3] In this cohort of obese patients who underwent THA, the WHO obesity class was not associated with risk, invasiveness, or timing of reoperations. (10.1016/j.arth.2025.07.026)
  • [L5] The authors conclude that current evidence does not support the routine use of tibial stem extensions in obese total knee arthroplasty patients due to insufficient, heterogeneous, and very low certainty data, though specific designs may benefit selected populations. (10.1016/j.arth.2025.11.056)
  • [L3] These findings suggest modern surgical practices and implant designs may have mitigated traditional obesity-related risks. (10.1016/j.arth.2026.04.031)
  • [L4] Overall, these findings suggested that obesity had a negative influence on lower extremity long bone fracture in-hospital outcomes. (10.1186/s12891-025-09349-6)
  • [L3] BMI has a weak-to-moderate association with peri-incisional adiposity in primary total joint arthroplasty patients. (10.1016/j.arth.2024.08.020)
  • [L3] Obese and overweight patients converted to THA at significantly higher rates compared with normal-weight patients. (10.1177/03635465251400355)
  • [L3] However, obesity remains a critical risk factor for mechanical failures. (10.1016/j.jisako.2025.100861)
  • [L2] Overall, T2DM is not an independent risk factor for reoperation when adjusted for BMI. (10.1186/s12891-026-09568-5)
  • [L5] Obesity and preexisting osteoarthritis are known risk factors for predicting poor outcomes and conversion to arthroplasty after knee arthroscopy, but the study lacks a control group and specific procedural details to determine if the surgery itself drives progression versus patient factors. (10.1016/j.arthro.2025.04.036)
  • [L3] Obesity has an increased risk of all-cause revisions and revision for instability or dislocation in patients receiving rTSA indicated for fractures. (10.1016/j.jse.2025.05.036)
  • [L3] Semaglutide appears to be a safe alternative to bariatric surgery for weight management before THA, with similar implant survival and postoperative complication rates. (10.1016/j.arth.2025.08.068)
  • [L3] Based on AOANJRR data, obese patients are at increased risk of higher rate of revision following UKA. (10.1177/2325967125s00336)
  • [L3] Unlike BMI, the STiB ratio reflects local anatomical factors that directly influence surgical exposure and wound healing. (10.1016/j.arth.2025.09.022)
  • [L1] Following MMPRT repair, repairs show progression of osteoarthritis with higher rates seen with elevated BMI. (10.1002/arj.70028)
  • [L2] However, a nonsignificant trend toward a higher complication rate was observed in patients with severe obesity (BMI ≥35 kg/m2), while a statistically significant increase in arthrofibrosis was found in patients with BMI <25 kg/m2. (10.1016/j.jisako.2025.100927)
  • [L3] Our findings support a BMI-based approach to perioperative semaglutide use, particularly in patients who have a BMI >30. (10.1016/j.arth.2025.09.056)
  • [L2] High BMI elevates the risk of both knee and hand osteoarthritis irrespective of metabolic status, and the increased risk of knee osteoarthritis attributed to high BMI is more evident in metabolically healthy participants. (10.1186/s12891-026-09495-5)
  • [L3] In morbidly obese patients, DM implants demonstrated excellent five-year survivorship with outcomes comparable or slightly superior to fixed-bearing constructs. (10.1016/j.arth.2026.03.075)
  • [L3] Hip arthroscopy for the treatment of FAI and labral tears in patients with obesity yielded significant and sustainable long-term improvements, which were equivalent to those of a benchmark matched control group of normal-weight patients. (10.1177/03635465251392585)
  • [L1] Total weight loss % was higher in bariatric surgery patients (28.7%, P < 0.001). (10.1016/j.arth.2026.05.033)
  • [L4] This multicenter data set has demonstrated improved patient-reported symptoms at the time of surgery, a decrease in mean patient BMI, and an increase in symptom duration reported prior to surgery. (10.1002/ksa.12745)
  • [L3] The ten-year functional outcomes and revision rates of THA do not justify restricting access to surgery on the basis of BMI. (10.1016/j.arth.2025.07.044)
  • [L3] Elevated BMI was associated with weak-to-moderate increases in thromboembolic risk after TSA but not infection or revision surgery. (10.1016/j.jse.2026.05.022)

References

[1] Letter to the Editor Commenting on: "Current Evidence Does Not Support the Use of Tibial Stem Extension in Total Knee Arthroplasty of Obese Patients: A Systematic Review". The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.11.047

[2] Body Mass Index > 40 Is Not Correlated With Early Complications in Patients Undergoing Primary Total Joint Arthroplasty at an Ambulatory Surgical Center. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.08.065

[3] Body Mass Index of 45 Is a Safe Cut-Off for Cementless Total Knee Arthroplasty. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2025.12.038

[4] Body mass index does not affect clinical outcomes following arthroscopically assisted posterior latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears: a minimum 5-year follow-up study. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2025.100634

[5] Reframing Obesity in Knee Osteoarthritis: A Call for a Transdisciplinary Approach Beyond Biomechanics. Arthroscopy. 2026. DOI: 10.1002/arj.70051

[6] Obesity Severity and Stiffness After Total Knee Arthroplasty Revisited: A Contemporary Analysis of Patients Requiring Manipulation Under Anesthesia. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.080

[7] Obesity Class Does Not Associate With Incidence, Timing, or Invasiveness of Reoperations After Total Hip Arthroplasty. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.07.026

[8] Reply to: "Letter to the Editor Commenting on: 'Current Evidence Does Not Support the Use of Tibial Stem Extension in Total Knee Arthroplasty of Obese Patients: A Systematic Review'". The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.11.056

[9] Obesity and Total Knee Arthroplasty Revisited: Minimal Impact on Loosening and Mechanical Failure in the Modern Era. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.04.031

[10] Impact of pediatric obesity on surgical outcomes of lower extremity fractures: a nationwide analysis (2010–2019). BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-025-09349-6

[11] Body Mass Index is Not an Appropriate Proxy for the Condition of Peri-Incisional Adiposity in Primary Total Joint Arthroplasty Patients. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.08.020

[12] The Effect of Body Mass Index on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Matched Analysis With 10-Year Follow-up. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465251400355

[13] Impact of high body mass index on functionally aligned image-based robotic total knee arthroplasty: Comparable functional outcomes but higher mechanical failures. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100861

[14] Type 2 diabetes is not associated with excess risk of periprosthetic joint infection in obese patients undergoing total hip arthroplasty. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09568-5

[15] Editorial Commentary: Obesity and Osteoarthritis Are Risk Factors for Conversion to Arthroplasty, With or Without Previous Knee Arthroscopic Surgery. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.04.036

[16] Revision rates between obese and nonobese total shoulder arthroplasty patients: an Australian registry data study. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.05.036

[17] Is Semaglutide a Safer Weight-Management Option Than Bariatric Surgery for Patients Undergoing Total Hip Arthroplasty (THA)?. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.08.068

[18] Obesity is Associated with Higher Rates of Revision Following Unicompartmental Knee Arthroplasty. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967125s00336

[19] Soft Tissue-To-Bone Ratio Outperforms Body Mass Index in Predicting Periprosthetic Joint Infection in Total Knee Arthroplasty: A Retrospective Case-Control Study. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.09.022

[20] Medial Meniscus Posterior Root Tear Repairs Show Osteoarthritis Progression Over Time With Higher Rates Seen With Higher Body Mass Index. Arthroscopy. 2026. DOI: 10.1002/arj.70028

[21] Impact of body mass index on robotic-assisted total knee arthroplasty outcomes: A retrospective cohort analysis. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100927

[22] The Effect of Body Mass Index on the Efficacy of Semaglutide Use at the Time of Total Knee Arthroplasty. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.09.056

[23] Does metabolically healthy obesity increase the risk of knee and hand osteoarthritis? A population-based cohort study. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09495-5

[24] Primary Total Hip Arthroplasty in Patients Who Have Morbid Obesity: A Propensity-Weighted Analysis of Dual Mobility and Standard Fixed-Bearing Implants. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.075

[25] Obese Patients Treated by Hip Arthroscopy for Femoroacetabular Impingement Syndrome — 10-Year Functional Outcomes and Conversion Rates to Arthroplasty Compared With Normal-Weight Patients. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465251392585

[26] Impact Of Prior Bariatric Surgery Versus Immediate Total Knee Arthroplasty On Knee Function Among Patients Who Have Severe Obesity And Advanced Knee Osteoarthritis: The SWIFT Trial. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.05.033

[27] Lower body mass index and symptom burden in modern hip arthroscopy patients: Updated epidemiology and trends from the MASH multicenter cohort. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12745

[28] Do the Ten-Year Functional Outcomes and Revision Rates of Total Hip Arthroplasty in Obese and Morbidly Obese Patients Justify Restricting Their Access to Surgery?. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.07.044

[29] Overweight and Premorbid Obesity Status Correlates With Thromboembolism Risk but Not Infection After Total Shoulder Arthroplasty. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.05.022

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4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.