Abstract
BACKGROUND: Obesity adversely affects outcomes in total knee arthroplasty (TKA), with higher rates of infection, wound complications, and early revision particularly noted in patients with BMI > 35 kg/m(2). While BMI is traditionally used to assess surgical risk, recent evidence suggests it may not reliably predict intraoperative challenges or wound healing outcomes. Instead, distribution of adiposity-such as increased limb girth or deep soft tissue thickness-may better correlate with surgical complexity. A shift toward assessing obesity phenotype rather than BMI alone can lead to better perioperative planning and tailored interventions. This approach is especially relevant in resource-constrained settings where the dual burden of obesity and limited healthcare access complicates care. In India, the absence of national guidelines and obesity-specific care pathways creates inconsistency in surgical decision-making. A growing body of evidence supports the need for comprehensive preoperative optimization-including weight reduction, glycemic control, nutritional support, and physiotherapy. Emerging strategies such as robotic-assisted surgery, patient-specific instrumentation, and Enhanced Recovery After Surgery (ERAS) protocols show promise in improving outcomes for obese patients. This review highlights the need for a personalized, evidence-based approach to TKA in obese individuals. METHODS: A narrative review of contemporary literature was undertaken to assess the impact of obesity on TKA outcomes, alternative measures of adiposity, preoperative optimization strategies, and emerging technologies aimed at improving results in obese patients. PURPOSE: This review examines the limitations of BMI-based risk stratification and explores the relevance of obesity phenotype in influencing perioperative complexity and outcomes in TKA, with emphasis on the Indian healthcare context. RESULTS: Current evidence suggests that BMI poorly predicts intraoperative challenges and wound healing complications. Measures reflecting adiposity distribution - such as limb girth and soft tissue thickness demonstrate stronger associations with surgical exposure, Noperative difficulty, and postoperative wound issues. Multimodal preoperative optimization, including weight reduction, glycaemic control, nutritional support, and physiotherapy, has been shown to reduce complication rates. Technological adjuncts such as roboticassisted Nsurgery, patient-specific instrumentation, and Enhanced Recovery After Surgery (ERAS) protocols may further improve outcomes. In India, the absence of standardized obesity-specific perioperative pathways contributes to variability in surgical decisionmaking. CONCLUSION: shift from BMI-based assessment to a phenotype-driven, individualized approach may allow better risk stratification and perioperative planning in obese patients undergoing TKA. Development of context-specific guidelines and structured optimization pathways is essential to improve outcomes in resource-constrained settings.