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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.

40 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Obesity is a modifiable systemic disease with profound inflammatory consequences on joint health that extend beyond mechanical burden [8]. While there is confusion regarding the relative contributions of diet and physical inactivity to obesity [4], addressing the condition can improve both orthopaedic and overall health in children [1]. Paradoxically, each 1-unit increase in BMI is associated with a 9% reduction in osteoporosis risk [2]. 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 [6].

In the context of joint replacement, BMI has a weak-to-moderate association with peri-incisional adiposity in primary total joint arthroplasty patients [10]. However, 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 [9]. The ten-year functional outcomes and revision rates of total hip arthroplasty do not justify restricting access to surgery on the basis of BMI [40]. Furthermore, focusing on management of preoperative comorbidities and custom surgical planning can achieve outcomes comparable to those of patients who have normal BMIs at ambulatory surgical centers [3].

Despite these insights, very few patients who have obesity received preoperative weight loss management before total knee arthroplasty or total hip arthroplasty via medications, nutrition services, or bariatric surgery regardless of sex or socioeconomic status [11]. Specific procedural considerations include the fact that the numbers were too small to draw conclusions in patients who have a BMI ≥ 45 regarding the safety of cementless total knee arthroplasty [5]. 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 [14]. The surgeon's obesity-specific annual primary total hip arthroplasty volume was not associated with the risk of revision or periprosthetic joint infection in patients who had a BMI ≥ 40 [27].

How It Works

Current clinical attention disproportionately focuses on diet and obesity rather than physical inactivity and obesity [4]. While modern surgical practices and implant designs may have mitigated traditional obesity-related risks regarding loosening and mechanical failure in total knee arthroplasty [15], obesity remains a critical risk factor for mechanical failures in functionally aligned image-based robotic total knee arthroplasty [18]. Additionally, obese patients face an increased risk of a higher rate of revision following unicompartmental knee arthroplasty [21]. 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) [23].

Obesity exerts a negative influence on lower extremity long bone fracture in-hospital outcomes [17]. Regarding joint degeneration, high BMI elevates the risk of both knee and hand osteoarthritis irrespective of metabolic status [33]. The increased risk of knee osteoarthritis attributed to high BMI is more evident in metabolically healthy participants [33]. Central obesity is significantly associated with the risk of glenohumeral joint osteoarthritis, especially in secondary glenohumeral joint osteoarthritis and normal BMI populations [35]. Following medial meniscus posterior root tear repair, repairs show progression of osteoarthritis with higher rates seen with elevated BMI [31]. Furthermore, obesity and preexisting osteoarthritis are known risk factors for predicting poor outcomes and conversion to arthroplasty after knee arthroscopy [24].

In the postoperative setting, increasing obesity severity is not associated with higher rates of postoperative stiffness or inferior outcomes following manipulation under anesthesia after total knee arthroplasty [9]. Type 2 diabetes is not an independent risk factor for reoperation when adjusted for BMI in obese patients undergoing total hip arthroplasty [20]. Surgical planning must account for the fact that the soft tissue-to-bone ratio reflects local anatomical factors that directly influence surgical exposure and wound healing, unlike BMI [30].

Metabolic and lifestyle interventions play a distinct role in joint health. Cardiorespiratory fitness is a strong predictor of cardiovascular disease and all-cause mortality and attenuates risks associated with overweight and obesity [34]. 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 [16]. An aggregate exercise programme energy expenditure of >10 000 kcal may be required to promote reductions in intrahepatic fat [19]. A BMI-based approach to perioperative semaglutide use is supported, particularly in patients who have a BMI >30 [32].

What the Evidence Shows

General Pathophysiology and Systemic Effects

Obesity is a systemic disease with profound inflammatory consequences on joint health, extending beyond mechanical burden on the knee [8]. There is significant confusion regarding the relationship between energy intake and expenditure in obesity, with greater attention historically focused on diet than on physical inactivity [4].

Bone Health and Metabolic Associations

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 [19].

Pediatric Orthopaedics

Obesity has a negative influence on in-hospital outcomes for lower extremity long bone fractures in pediatric patients [17].

Total Knee Arthroplasty (TKA)

Complication and Outcome Profiles: BMI greater than 40 is not correlated with early complications in patients undergoing primary TKA at an ambulatory surgical center when preoperative comorbidities are managed and surgical planning is customized [3]. Increasing obesity severity is not associated with higher rates of postoperative stiffness or inferior outcomes following manipulation under anesthesia (MUA) [9]. A nonsignificant trend toward a higher complication rate was observed in patients with severe obesity (BMI ≥35 kg/m2) undergoing robotic-assisted TKA [23].

Implant and Surgical Strategy: BMI of 45 is identified as a safe cut-off for cementless TKA, though sample sizes were too small to draw conclusions for patients with a BMI of 45 or higher [5]. 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 [14]. Modern surgical practices and implant designs may have mitigated traditional obesity-related risks regarding loosening and mechanical failure in TKA [15]. However, obesity remains a critical risk factor for mechanical failures in functionally aligned image-based robotic TKA, despite comparable functional outcomes [18].

Anatomic and Revision Considerations: BMI has a weak-to-moderate association with peri-incisional adiposity in primary TKA patients [10]. Obese patients are at increased risk of a higher rate of revision following unicompartmental knee arthroplasty (UKA) [21]. Total weight loss percentage was higher in bariatric surgery patients (28.7%) compared to those undergoing immediate TKA for severe obesity and advanced knee osteoarthritis [37].

Total Hip Arthroplasty (THA)

Reoperation and Risk Factors: WHO obesity class is not associated with the risk, invasiveness, or timing of reoperations after THA in obese patients [12]. Type 2 diabetes is not an independent risk factor for reoperation in obese patients undergoing THA when adjusted for BMI [20].

Weight Management and Implant Design: Semaglutide appears to be a safe alternative to bariatric surgery for weight management before THA, with similar implant survival and postoperative complication rates [25]. Dual mobility implants demonstrated excellent five-year survivorship with outcomes comparable or slightly superior to fixed-bearing constructs in morbidly obese patients undergoing primary THA [36].

Shoulder Arthroplasty

BMI was not associated with an increased risk of revision in primary anatomic total shoulder arthroplasty (aTSA) for osteoarthritis or primary reverse total shoulder arthroplasty (rTSA) for rotator cuff arthropathy [22]. Overweight and premorbid obesity status correlates with thromboembolism risk but not infection after total shoulder arthroplasty [28].

Arthroscopy and Soft Tissue Surgery

Rotator Cuff and Hip Arthroscopy: BMI does not affect clinical outcomes following arthroscopically assisted posterior latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears [7]. Obese and overweight patients converted to THA at significantly higher rates compared with normal-weight patients after hip arthroscopy for femoroacetabular impingement syndrome [13]. Patients with obesity had greater than 2-fold odds of conversion to THA compared with normal-weight patients after hip arthroscopy for femoroacetabular impingement syndrome [26].

Knee Arthroscopy and Cohort Trends: Obesity and preexisting osteoarthritis are risk factors for predicting poor outcomes and conversion to arthroplasty after knee arthroscopy [24]. 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 [39].

Weight Management and Exercise Interventions

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 [6]. When combined with liraglutide treatment, exercise results in a more holistic state of health that may improve longer-term health, enhance treatment adherence, and promote longer-term weight-loss maintenance [16]. Women with sarcopenic obesity who underwent high-intensity interval training (HIIT) had significant reductions in weight and BMI compared to those who followed a moderate-intensity continuous training (MICT) protocol [38]. Very few patients with obesity received preoperative weight loss management before TKA or THA via medications, nutrition services, or bariatric surgery, regardless of sex or socioeconomic status [11].

Practical Considerations

Patient Selection and Risk Stratification

BMI > 40 is not correlated with early complications in patients undergoing primary total joint arthroplasty at an ambulatory surgical center [3]. A BMI of 45 is identified as a safe cut-off for cementless total knee arthroplasty, though sample sizes were too small to draw conclusions for patients with a BMI ≥ 45 [5]. Obesity class is not associated with the risk, invasiveness, or timing of reoperations after total hip arthroplasty [12]. Furthermore, BMI is not associated with an increased risk of revision in primary anatomic total shoulder arthroplasty indicated for osteoarthritis or primary reverse total shoulder arthroplasty indicated for rotator cuff arthropathy [22].

Rising body mass index increased early complications, but not early reoperations, following aseptic revision total knee arthroplasty [29]. In pediatric populations, obesity had a negative influence on lower extremity long bone fracture in-hospital outcomes [17].

Surgical Outcomes and Complications

Obesity remains a critical risk factor for mechanical failures in functionally aligned image-based robotic total knee arthroplasty, despite comparable functional outcomes [18].

Preoperative Management and Weight Loss

Very few patients who have obesity received preoperative weight loss management before total knee arthroplasty or total hip arthroplasty via medications, nutrition services, or bariatric surgery [11]. 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 [25]. Obesity is modifiable, and addressing the issue can improve the orthopaedic and overall health of children [1].

Measurement and Pathophysiology

Each 1-unit increase in BMI was associated with a 9% reduction in osteoporosis risk [2]. Obesity is a systemic disease with profound inflammatory consequences on joint health beyond mechanical burden [8]. There is more attention focused on diet and obesity than on physical inactivity and obesity regarding the relation of energy intake and energy expenditure to obesity [4].

Implant Design and Technique

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 [14].

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)
  • [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. [4] (10.1136/bjsports-2015-094911)
  • [L3] However, the numbers were too small to draw conclusions in patients who have a BMI ≥ 45. [5] (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. [6] (10.1136/bjsports-2023-107252)
  • [L2] No significant differences were observed between above-average and below-average BMI groups, and BMI was not correlated with clinical improvements. [7] (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. [8] (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. [9] (10.1016/j.arth.2026.03.080)
  • [L3] BMI has a weak-to-moderate association with peri-incisional adiposity in primary total joint arthroplasty patients. [10] (10.1016/j.arth.2024.08.020)
  • [L3] Very few patients who have obesity received preoperative weight loss management before TKA or THA via medications, nutrition services, or bariatric surgery regardless of sex or socioeconomic status. [11] (10.1016/j.arth.2026.06.021)
  • [L3] In this cohort of obese patients who underwent THA, the WHO obesity class was not associated with risk, invasiveness, or timing of reoperations. [12] (10.1016/j.arth.2025.07.026)
  • [L3] Obese and overweight patients converted to THA at significantly higher rates compared with normal-weight patients. [13] (10.1177/03635465251400355)
  • [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. [14] (10.1016/j.arth.2025.11.056)
  • [L3] These findings suggest modern surgical practices and implant designs may have mitigated traditional obesity-related risks. [15] (10.1016/j.arth.2026.04.031)
  • [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. [16] (10.1136/bjsports-2021-104754)
  • [L4] Overall, these findings suggested that obesity had a negative influence on lower extremity long bone fracture in-hospital outcomes. [17] (10.1186/s12891-025-09349-6)
  • [L3] However, obesity remains a critical risk factor for mechanical failures. [18] (10.1016/j.jisako.2025.100861)
  • [L1] An aggregate exercise programme energy expenditure (>10 000 kcal) may be required to promote reductions in intrahepatic fat. [19] (10.1136/bjsports-2016-096197)
  • [L2] Overall, T2DM is not an independent risk factor for reoperation when adjusted for BMI. [20] (10.1186/s12891-026-09568-5)
  • [L3] Based on AOANJRR data, obese patients are at increased risk of higher rate of revision following UKA. [21] (10.1177/2325967125s00336)
  • [L3] BMI was not associated with an increased risk of revision in primary aTSA indicated for osteoarthritis, nor for primary rTSA indicated for rotator cuff arthropathy. [22] (10.1016/j.jse.2025.05.036)
  • [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. [23] (10.1016/j.jisako.2025.100927)
  • [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. [24] (10.1016/j.arthro.2025.04.036)
  • [L3] Semaglutide appears to be a safe alternative to bariatric surgery for weight management before THA, with similar implant survival and postoperative complication rates. [25] (10.1016/j.arth.2025.08.068)
  • [L3] However, patients with obesity had >2-fold odds of conversion to THA. [26] (10.1177/03635465251392585)
  • [L3] However, the surgeon's obesity-specific annual primary THA volume was not associated with the risk of revision or PJI in patients who had a BMI ≥ 40. [27] (10.1016/j.arth.2025.07.037)
  • [L3] These findings support individualized thromboembolic risk assessment while suggesting TSA remains relatively safe in patients with elevated BMI. [28] (10.1016/j.jse.2026.05.022)
  • [L3] Otherwise, the complication profile was similar across the spectrum of BMI values. [29] (10.1016/j.arth.2026.01.024)
  • [L3] Unlike BMI, the STiB ratio reflects local anatomical factors that directly influence surgical exposure and wound healing. [30] (10.1016/j.arth.2025.09.022)
  • [L1] Following MMPRT repair, repairs show progression of osteoarthritis with higher rates seen with elevated BMI. [31] (10.1002/arj.70028)
  • [L3] Our findings support a BMI-based approach to perioperative semaglutide use, particularly in patients who have a BMI >30. [32] (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. [33] (10.1186/s12891-026-09495-5)
  • [L1] CRF is a strong predictor of CVD and all-cause mortality and attenuates risks associated with overweight and obesity. [34] (10.1136/bjsports-2024-108748)
  • [L2] Central obesity is significantly associated with the risk of glenohumeral joint osteoarthritis, especially in secondary GJO and normal BMI populations, suggesting that fat distribution should be included in the early screening and risk assessment system for GJO. [35] (10.1016/j.jse.2025.07.007)
  • [L3] In morbidly obese patients, DM implants demonstrated excellent five-year survivorship with outcomes comparable or slightly superior to fixed-bearing constructs. [36] (10.1016/j.arth.2026.03.075)
  • [L1] Total weight loss % was higher in bariatric surgery patients (28.7%, P < 0.001). [37] (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. [38] (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. [39] (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. [40] (10.1016/j.arth.2025.07.044)

See Also

  • Osteoarthritis

References

[1] The Role of Obesity in Pediatric Orthopedics. JAAOS: Global Research and Reviews. 2019. DOI: 10.5435/jaaosglobal-d-19-00036

[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] 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

[5] 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

[6] 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

[7] 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

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

[9] 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

[10] 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

[11] 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

[12] 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

[13] 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

[14] 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

[15] 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

[16] 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

[17] 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

[18] 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

[19] 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

[20] 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

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

[22] 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

[23] 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

[24] 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

[25] 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

[26] 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

[27] Effects of Surgeon Volume on Outcomes Following Primary Total Hip Arthroplasty in the Morbidly Obese: An Analysis From the American Joint Replacement Registry. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.07.037

[28] 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

[29] Rising Body Mass Index Increased Early Complications, But Not Early Reoperations Following Aseptic Revision Total Knee Arthroplasty. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.01.024

[30] 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

[31] 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

[32] 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

[33] 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

[34] Cardiorespiratory fitness, body mass index and mortality: a systematic review and meta-analysis. British Journal of Sports Medicine. 2024. DOI: 10.1136/bjsports-2024-108748

[35] Association between central obesity and the risk of glenohumeral joint osteoarthritis: a prospective study. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.07.007

[36] 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

[37] 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

[38] Impact of high-intensity interval training vs. moderate-intensity continuous training combined with strength training on physical and metabolic outcomes in post-bariatric surgery patients with sarcopenic obesity. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09722-z

[39] 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

[40] 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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c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

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.