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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.

50 citationsUpdated Oct 2026
Illustration: Weight, Obesity and Joint Health

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Overview

Obesity is a modifiable systemic disease with profound inflammatory consequences on joint health that extend beyond mechanical burden [11]. Addressing this condition can improve both orthopaedic and overall health in children [1]. The pathophysiology involves altered cartilage contact location, primarily in the medial compartment, which contributes to the high prevalence of medial knee osteoarthritis in the obese population [17]. While there is significant confusion regarding the relation of energy intake and expenditure to obesity, with more attention focused on diet than physical inactivity [5], physical activity equivalent to approximately 30–35 min of vigorous intensity per week appears to offset the association between abdominal obesity and incident cardiovascular disease [10].

Clinically, overweight and obese patients require total hip and total knee arthroplasty at a significantly younger age than normal-weight patients [18]. Increased body mass index among patients with a total joint replacement is associated with decreased ambulatory activity [13]. In pediatric and adolescent populations, increased CDC weight category is associated with worsening clinical outcomes across all measures following meniscus repair [8]. Conversely, each 1-unit increase in BMI was associated with a 9% reduction in osteoporosis risk based on a dose–response analysis of nine studies [2]. Underweight patients demonstrated an elevated risk for complications that overlapped with those seen in obese patients, yet experienced lower rates of other complications following lower extremity fracture fixation [6].

Management options for weight loss are numerous for both individuals and physicians [14]. Current evidence does not support restricting access to surgery on the basis of BMI, as ten-year functional outcomes and revision rates of total hip arthroplasty do not justify such restrictions [51]. In a cohort of obese patients who underwent total hip arthroplasty, the WHO obesity class was not associated with risk, invasiveness, or timing of reoperations [21]. Increasing obesity severity is not associated with higher rates of postoperative stiffness or inferior outcomes following manipulation under anesthesia, and concern for stiffness alone should not serve as a categorical barrier to total knee arthroplasty or manipulation under anesthesia when clinically indicated [12]. Focusing on management of preoperative comorbidities and custom surgical planning can achieve outcomes comparable to those of patients with normal BMIs at ambulatory surgical centers, questioning BMI as an exclusion criterion for primary total joint arthroplasty [3].

How It Works

Systemic and Metabolic Mechanisms

Obesity is a systemic disease with profound inflammatory consequences on joint health [11]. At the cellular level, obesity promotes lipid accumulation in mouse cartilage via acetyl-CoA carboxylase (ACC) mediated chondrocyte de novo lipogenesis [41]. Inhibition of ACC ameliorates this lipid accumulation, suggesting ACC could potentially be targeted to treat obesity-associated osteoarthritis [41]. Skeletal effects extend beyond cartilage; diet-induced obesity significantly alters bone morphology and mineral density in a manner dependent on dietary free fatty acid content [40]. Adolescent murine obesity alters structural, mechanical, and compositional properties of bone, which may have lasting implications on bone health even after obesity is corrected [36].

Current understanding of energy balance remains complex, with confusion regarding the relation of energy intake and energy expenditure to obesity, where more attention is focused on diet than physical inactivity [5]. An aggregate exercise programme energy expenditure greater than 10,000 kcal may be required to promote reductions in intrahepatic fat [20]. When combined with liraglutide treatment, exercise results in a more holistic state of health that may enhance adherence and promote longer-term weight-loss maintenance [19].

Biomechanics and Joint Loading

Obesity affects knee cartilage contact location mainly in the medial compartment, explaining part of the high prevalence of medial knee osteoarthritis in the obese population [17]. Articular cartilage may not adapt to higher joint loads in adults with obesity [39]. Aging and obesity are both associated with a loss of the positive relationship between cartilage thickness and ambulatory loads [23]. Under weight-bearing conditions, patellofemoral joint contact areas increased by an average of 24% [43]. Notably, obesity did not enhance cartilage degeneration in the absence of fracture or surgical trauma [34].

Clinical Outcomes and Complications

Obesity influences both degenerative and traumatic outcomes. Each 1-unit increase in BMI is associated with a 9% reduction in osteoporosis risk [2]. Following medial meniscus posterior root tear repair, osteoarthritis progression occurs at higher rates with elevated BMI [38]. In trauma care, obesity is associated with higher 90-day and 2-year complication rates following surgical fixation of upper extremity fractures [26]. At 2 years, obese patients demonstrate increased risks of malunion, nonunion, and revision following upper extremity fracture fixation [26]. Conversely, underweight patients demonstrate an elevated risk for complications that overlap with those seen in obese patients following lower extremity fracture fixation [6]. Physical activity equivalent to approximately 30–35 minutes of vigorous intensity per week appears to offset the association between abdominal obesity and incident cardiovascular disease [10].

Surgical Considerations and Risk Stratification

BMI has a weak-to-moderate association with peri-incisional adiposity in primary total joint arthroplasty patients [27]. The soft tissue-to-bone ratio reflects local anatomical factors that directly influence surgical exposure and wound healing, unlike BMI [35]. Modern surgical practices and implant designs may have mitigated traditional obesity-related risks regarding loosening and mechanical failure in total knee arthroplasty [24]. However, obesity remains a critical risk factor for mechanical failures in functionally aligned image-based robotic total knee arthroplasty [28]. In robotic-assisted total knee arthroplasty, a nonsignificant trend toward a higher complication rate was observed in patients with severe obesity (BMI ≥35 kg/m2) [42]. In robotic-assisted total knee arthroplasty, a statistically significant increase in arthrofibrosis was found in patients with BMI <25 kg/m2 [42].

Regarding postoperative stiffness, increasing obesity severity is not associated with higher rates of postoperative stiffness or inferior outcomes following manipulation under anesthesia for total knee arthroplasty [12]. Concern for stiffness alone should not serve as a categorical barrier to total knee arthroplasty or manipulation under anesthesia when clinically indicated [12]. Focusing on management of preoperative comorbidities and custom surgical planning can achieve outcomes comparable to those of patients with normal BMIs at ambulatory surgical centers for primary total joint arthroplasty [3]. BMI > 40 is not correlated with early complications in patients undergoing primary total joint arthroplasty at an ambulatory surgical center [3]. No significant differences were observed between above-average and below-average BMI groups regarding clinical outcomes following arthroscopically assisted posterior latissimus dorsi tendon transfer [16]. BMI was not correlated with clinical improvements following arthroscopically assisted posterior latissimus dorsi tendon transfer [16].

Trauma and the Obesity Paradox

Mortality did not decrease in association with increasing BMI in isolated blunt abdominal trauma, as this may be offset by the increase in co-morbidities [4]. The "Obesity Paradox" in major trauma is a reproducible phenomenon where biomechanical protection resulting in a lower Injury Severity Score neutralizes the increased physiological and comorbidity burden of the obese state [37].

Pediatric and Modifiability

Obesity is modifiable, and addressing the issue can improve the orthopaedic and overall health of children [1].

What the Evidence Shows

Systemic and General Associations

Obesity is a systemic disease with profound inflammatory consequences on joint health, extending beyond mechanical burden on the knee [11]. Current understanding of the relationship between energy intake and expenditure remains confused, with more attention focused on diet than physical inactivity [5]. In the context of isolated blunt abdominal trauma, mortality did not decrease in association with increasing BMI, potentially due to increased co-morbidities [4]. Regarding metabolic interventions, an aggregate exercise programme energy expenditure greater than 10,000 kcal may be required to promote reductions in intrahepatic fat in adults who are overweight or have fatty liver disease [20]. Furthermore, women with high-intensity interval training (HIIT) had a significant reduction in weight and BMI compared to those who followed a moderate-intensity continuous training (MICT) protocol [48].

Fracture Fixation and Trauma

Underweight patients demonstrated an elevated risk for complications that overlapped with those seen in obese patients, yet experienced lower rates of other complications in lower extremity fracture fixation [6]. At 2 years, obese patients demonstrated increased risks of malunion, nonunion, and revision following surgical fixation of upper extremity fractures [26]. Pediatric obesity substantially lengthened length of stay and encouraged undesirable discharge compared to non-obese individuals in lower extremity fractures [32]. Conversely, there was no difference in postoperative range of motion between normal weight and obese groups after surgical treatment of intra-articular distal radius fractures [46].

Joint Arthroplasty

The numbers in studies of cementless total knee arthroplasty were too small to draw conclusions in patients who have a BMI ≥ 45 [9]. Increasing obesity severity is not associated with higher rates of postoperative stiffness or inferior outcomes following manipulation under anesthesia (MUA) after total knee arthroplasty [12]. 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 [15]. Obesity class was not associated with risk, invasiveness, or timing of reoperations in a cohort of obese patients who underwent total hip arthroplasty [21]. However, obesity remains a critical risk factor for mechanical failures in functionally aligned image-based robotic total knee arthroplasty, despite comparable functional outcomes [28]. Obesity has an increased risk of all-cause revisions and revision for instability or dislocation in patients receiving reverse total shoulder arthroplasty indicated for fractures [29]. Obese patients are at increased risk of a higher rate of revision following unicompartmental knee arthroplasty [33]. In morbidly obese patients, dual mobility implants demonstrated excellent five-year survivorship with outcomes comparable or slightly superior to fixed-bearing constructs in primary total hip arthroplasty [44].

Preoperative weight management strategies show varied outcomes. Women had decreased odds of losing greater than five pounds before surgery despite increased odds of having preoperative bariatric surgery [31]. 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 [30]. Total weight loss percentage was higher in bariatric surgery patients (28.7%) compared to immediate total knee arthroplasty in patients with severe obesity and advanced knee osteoarthritis [47].

Arthroscopy and Soft Tissue

The absence of direct comparative studies precludes causal inference regarding the role of weight-bearing timing in medial meniscus posterior root tears repair [7]. 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 [22]. However, hip arthroscopy for the treatment of femoroacetabular impingement and labral tears in patients with obesity yielded significant and sustainable long-term improvements equivalent to those of a benchmark matched control group of normal-weight patients [45]. No significant differences were observed between above-average and below-average BMI groups, and BMI was not correlated with clinical improvements following arthroscopically assisted posterior latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears [16]. Obesity and preexisting osteoarthritis are known risk factors for predicting poor outcomes and conversion to arthroplasty after knee arthroscopy [50]. Multicenter data from the MASH cohort 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 in modern hip arthroscopy patients [49].

Practical Considerations

Pediatric and Adolescent Populations

Obesity constitutes a modifiable risk factor in pediatric patients; addressing it can improve both orthopaedic and overall health [1]. In lower extremity fracture cases, pediatric obesity substantially lengthens hospital length of stay and encourages undesirable discharge compared to non-obese individuals [32].

Biomechanics and Joint Pathology

Obesity affects knee cartilage contact location primarily in the medial compartment, explaining part of the high prevalence of medial knee osteoarthritis in the obese population [17]. Additionally, aging and obesity are both associated with a loss of the positive relationship between femoral articular cartilage thickness and ambulatory loads in individuals without osteoarthritis [23].

Arthroplasty: Total Hip Arthroplasty (THA)

Overweight and obese patients require total hip arthroplasty at a significantly younger age than normal-weight patients [18]. In a cohort of obese patients undergoing total hip arthroplasty, WHO obesity class was not associated with the risk, invasiveness, or timing of reoperations [21].

Arthroplasty: Total Knee Arthroplasty (TKA)

Overweight and obese patients require total knee arthroplasty at a significantly younger age than normal-weight patients [18]. Specific considerations regarding BMI and surgical outcomes include:

  • Primary TKA at ambulatory centers: BMI greater than 40 is not correlated with early complications in patients undergoing primary total knee arthroplasty at an ambulatory surgical center when preoperative comorbidities are managed and surgical planning is customized [3].
  • Unicompartmental knee arthroplasty: Obese patients are at increased risk of higher rates of revision following unicompartmental knee arthroplasty based on AOANJRR data [33].
  • Cementless TKA: The number of patients with a BMI ≥ 45 was too small to draw conclusions regarding the safety of cementless total knee arthroplasty in that specific group [9].

Arthroplasty: Other Joints

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 [29]. Conversely, body mass index does not affect clinical outcomes following arthroscopically assisted posterior latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears [16].

Fracture Fixation and Trauma

Preoperative Weight Management and Activity

An aggregate exercise programme energy expenditure greater than 10,000 kcal may be required to promote reductions in intrahepatic fat in adults who are overweight or exhibit fatty liver disease [20]. When combined with liraglutide treatment, exercise results in a more holistic state of health that may enhance adherence to the treatment and promote longer-term weight-loss maintenance [19]. There is confusion regarding the relation of energy intake and energy expenditure to obesity, with much more attention focused on diet than on physical inactivity [5].

Key Evidence

  • [L5] Obesity is modifiable, and addressing the issue can improve the orthopaedic and overall health of children. [1] (10.5435/jaaosglobal-d-19-00036)
  • [L1] Based on our dose–response analysis of nine studies, each 1-unit increase in BMI was associated with a 9% reduction in osteoporosis risk. [2] (10.1186/s12891-026-09675-3)
  • [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. [3] (10.1016/j.arth.2025.08.065)
  • [L3] Mortality did not decrease in association with increasing BMI, as this may be offset by the increase in co-morbidities in this population. [4] (10.1016/j.injury.2024.111612)
  • [L5] There is enormous confusion about the relation of energy intake and energy expenditure to obesity, with much more attention focused on diet and obesity than on physical inactivity and obesity. [5] (10.1136/bjsports-2015-094911)
  • [L3] Underweight patients demonstrated an elevated risk for complications that overlapped with those seen in obese patients, yet experienced lower rates of others. [6] (10.1016/j.injury.2025.112864)
  • [L4] However, the absence of direct comparative studies precludes causal inference regarding the role of weight-bearing timing. [7] (10.1002/arj.70529)
  • [L3] Increased CDC weight category is associated with worsening clinical outcomes across all measures. [8] (10.1016/j.injury.2026.113122)
  • [L3] However, the numbers were too small to draw conclusions in patients who have a BMI ≥ 45. [9] (10.1016/j.arth.2025.12.038)
  • [L3] Physical activity equivalent to approximately 30–35 min of vigorous intensity per week appears to offset the association between abdominal obesity and incident CVD. [10] (10.1136/bjsports-2023-107252)
  • [L5] Obesity is more than a mechanical burden on the knee; it is a systemic disease with profound inflammatory consequences on joint health. [11] (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. [12] (10.1016/j.arth.2026.03.080)
  • [L4] We therefore conclude that increased body mass index (greater obesity) among patients with a total joint replacement is associated with decreased ambulatory activity. [13] (10.1002/jor.1100180106)
  • [Paper] Both the individual and the physician have many options from which to choose when selecting an appropriate weight loss program. [14] (10.1016/s0278-5919(05)70176-9)
  • [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. [15] (10.1016/j.arth.2025.11.056)
  • [L2] No significant differences were observed between above-average and below-average BMI groups, and BMI was not correlated with clinical improvements. [16] (10.1016/j.xrrt.2025.100634)
  • [L4] These findings suggest that obesity affects the contact location mainly in the medial compartment, which explains, in part, the high prevalence of medial knee OA in the obese population. [17] (10.1002/jor.25288)
  • [L3] This is the first study to demonstrate the significantly earlier age at which THA and TKA are required for overweight patients and those in obese category 1, in addition to those in obesity categories 2 and 3. [18] (10.1002/jor.24460)
  • [Paper] It is clear that, when combined with liraglutide treatment, exercise results in a more holistic state of health that may result in improved longer-term health and may enhance adherence to the treatment and promote longer-term weight-loss maintenance. [19] (10.1136/bjsports-2021-104754)
  • [L1] An aggregate exercise programme energy expenditure (>10 000 kcal) may be required to promote reductions in intrahepatic fat. [20] (10.1136/bjsports-2016-096197)
  • [L3] In this cohort of obese patients who underwent THA, the WHO obesity class was not associated with risk, invasiveness, or timing of reoperations. [21] (10.1016/j.arth.2025.07.026)
  • [L3] Obese and overweight patients converted to THA at significantly higher rates compared with normal-weight patients. [22] (10.1177/03635465251400355)
  • [L4] These results suggest that aging and obesity are both associated with a loss of the positive relationship between cartilage thickness and ambulatory loads, and that the relationship is dependent on the compartment and whether the load is generated by body size or subject-specific gait mechanics. [23] (10.1002/jor.22530)
  • [L3] These findings suggest modern surgical practices and implant designs may have mitigated traditional obesity-related risks. [24] (10.1016/j.arth.2026.04.031)
  • [L3] At 2 years, obese patients demonstrated increased risks of malunion, nonunion, and revision. [26] (10.1016/j.injury.2025.112891)
  • [L3] BMI has a weak-to-moderate association with peri-incisional adiposity in primary total joint arthroplasty patients. [27] (10.1016/j.arth.2024.08.020)
  • [L3] However, obesity remains a critical risk factor for mechanical failures. [28] (10.1016/j.jisako.2025.100861)
  • [L3] Obesity has an increased risk of all-cause revisions and revision for instability or dislocation in patients receiving rTSA indicated for fractures. [29] (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. [30] (10.1016/j.arth.2025.08.068)
  • [L3] Women had decreased odds of losing greater than five pounds before surgery despite increased odds of having preoperative bariatric surgery. [31] (10.1016/j.arth.2026.06.021)
  • [L4] Obesity substantially lengthened length of stay and encouraged undesirable discharge when compared to non-obese individuals. [32] (10.1186/s12891-025-09349-6)
  • [L3] Based on AOANJRR data, obese patients are at increased risk of higher rate of revision following UKA. [33] (10.1177/2325967125s00336)
  • [Paper] Obesity did not enhance cartilage degeneration in the absence of fracture or surgical trauma. [34] (10.1002/jor.24799)
  • [L3] Unlike BMI, the STiB ratio reflects local anatomical factors that directly influence surgical exposure and wound healing. [35] (10.1016/j.arth.2025.09.022)
  • [Paper] Adolescent murine obesity alters structural, mechanical and compositional properties of the bone, which may have lasting implication on bone health even after the obesity is corrected. [36] (10.1002/jor.25378)
  • [L3] Our findings strongly suggest that the "Obesity Paradox" in major trauma is not a mere statistical anomaly, but a reproducible phenomenon with a distinct mechanistic explanation: Biomechanical protection, which results in a lower ISS, neutralizes the increased physiological and comorbidity burden of the obese state. [37] (10.1016/j.injury.2025.112913)
  • [L1] Following MMPRT repair, repairs show progression of osteoarthritis with higher rates seen with elevated BMI. [38] (10.1002/arj.70028)
  • [L4] These findings suggest that articular cartilage may not adapt to higher joint loads in adults with obesity. [39] (10.1002/jor.24655)
  • [Paper] Diet-induced obesity significantly altered bone morphology and mineral density in a manner that was dependent on dietary free fatty acid content. [40] (10.1002/jor.24219)
  • [Paper] This was supported by the observation that ACC inhibition ameliorated lipid accumulation in chondrocytes, thereby suggesting that ACC could potentially be targeted to treat obesity-associated OA. [41] (10.1002/jor.25322)
  • [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. [42] (10.1016/j.jisako.2025.100927)
  • [L4] Under weight-bearing conditions, contact areas increased by an average of 24% (p < 0.05). [43] (10.1016/j.orthres.2004.08.003)
  • [L3] In morbidly obese patients, DM implants demonstrated excellent five-year survivorship with outcomes comparable or slightly superior to fixed-bearing constructs. [44] (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. [45] (10.1177/03635465251392585)
  • [L3] There was no difference in postoperative range of motion between the normal weight and obese groups. [46] (10.1016/j.hansur.2019.09.004)
  • [L1] Total weight loss % was higher in bariatric surgery patients (28.7%, P < 0.001). [47] (10.1016/j.arth.2026.05.033)
  • [L1] Additionally, women with HIIT training had significant reduction in their weight and BMI compared to those who followed MICT training protocol. [48] (10.1186/s12891-026-09722-z)
  • [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. [49] (10.1002/ksa.12745)
  • [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. [50] (10.1016/j.arthro.2025.04.036)
  • [L3] The ten-year functional outcomes and revision rates of THA do not justify restricting access to surgery on the basis of BMI. [51] (10.1016/j.arth.2025.07.044)

See Also

  • Osteoarthritis

References

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[2] The association between body mass index and osteoporosis, with consideration of sex differences: a systematic review and dose-response meta-analysis. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09675-3

[3] 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

[4] An evaluation of the “Obesity Paradox” in isolated blunt abdominal trauma in the United States. Injury. 2024. DOI: 10.1016/j.injury.2024.111612

[5] It is time to bust the myth of physical inactivity and obesity: you cannot outrun a bad diet. British Journal of Sports Medicine. 2015. DOI: 10.1136/bjsports-2015-094911

[6] Weight on the fixation: the influence of body mass index on lower extremity fracture fixation outcomes. Injury. 2025. DOI: 10.1016/j.injury.2025.112864

[7] Suboptimal Clinical and Radiologic Outcomes After Medial Meniscus Posterior Root Tears Repair With Early Partial Weight‐Bearing: A Systematic Review. Arthroscopy. 2026. DOI: 10.1002/arj.70529

[8] Increased weight and BMI are associated with increased failure following meniscus repair in the pediatric and adolescent populations. Injury. 2026. DOI: 10.1016/j.injury.2026.113122

[9] 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

[10] Joint associations of device-measured physical activity and abdominal obesity with incident cardiovascular disease: a prospective cohort study. British Journal of Sports Medicine. 2023. DOI: 10.1136/bjsports-2023-107252

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

[12] 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

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[15] 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

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[18] Overweight and Obese Patients Require Total Hip and Total Knee Arthroplasty at a Younger Age. Journal of Orthopaedic Research. 2019. DOI: 10.1002/jor.24460

[19] Exercise in the maintenance of weight loss: health benefits beyond lost weight on the scale. British Journal of Sports Medicine. 2021. DOI: 10.1136/bjsports-2021-104754

[20] Effect of exercise training on liver function in adults who are overweight or exhibit fatty liver disease: a systematic review and meta-analysis. British Journal of Sports Medicine. 2016. DOI: 10.1136/bjsports-2016-096197

[21] 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

[22] 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

[23] Age and obesity alter the relationship between femoral articular cartilage thickness and ambulatory loads in individuals without osteoarthritis. Journal of Orthopaedic Research. 2013. DOI: 10.1002/jor.22530

[24] 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

[26] Obesity is associated with higher 90-day and 2-year complication rates following surgical fixation of upper extremity fractures: A nationwide analysis. Injury. 2025. DOI: 10.1016/j.injury.2025.112891

[27] 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

[28] 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

[29] 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

[30] 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

[31] Disparities in Preoperative Weight Loss and Obesity Treatment Before Total Joint Arthroplasty. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.06.021

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

[34] Obesity and load‐induced posttraumatic osteoarthritis in the absence of fracture or surgical trauma. Journal of Orthopaedic Research. 2020. DOI: 10.1002/jor.24799

[35] 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

[36] Adolescent obesity incurs adult skeletal deficits in murine induced obesity model. Journal of Orthopaedic Research. 2022. DOI: 10.1002/jor.25378

[37] Neutralizing the odds: Biomechanical protection by adiposity offsets physiological burden to explain the trauma ’obesity-paradox’. Injury. 2026. DOI: 10.1016/j.injury.2025.112913

[38] 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

[39] Body mass index moderates the association between gait kinetics, body composition, and femoral knee cartilage characteristics. Journal of Orthopaedic Research. 2020. DOI: 10.1002/jor.24655

[40] Effects of dietary fatty acid content on humeral cartilage and bone structure in a mouse model of diet‐induced obesity. Journal of Orthopaedic Research. 2019. DOI: 10.1002/jor.24219

[41] Obesity promotes lipid accumulation in mouse cartilage—A potential role of acetyl‐CoA carboxylase (ACC) mediated chondrocyte de novo lipogenesis. Journal of Orthopaedic Research. 2022. DOI: 10.1002/jor.25322

[42] 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

[43] Patellofemoral joint contact area increases with knee flexion and weight‐bearing. Journal of Orthopaedic Research. 2005. DOI: 10.1016/j.orthres.2004.08.003

[44] 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

[45] 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

[46] Influence of body mass index on health-related quality of life after surgical treatment of intra-articular distal radius fractures. A retrospective 7-year follow-up study. Hand Surgery and Rehabilitation. 2019. DOI: 10.1016/j.hansur.2019.09.004

[47] 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

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[50] 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

[51] 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

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