An intensive, 18-week lifestyle medicine (LSM) program helped high-risk patients with osteoarthritis mitigate infections and pain after knee or hip surgery compared with those with standard-of-care, according to data presented at American College of Lifestyle Medicine (ACLM) 2025.
Heidi Prather, DO, professor of physical medicine and rehabilitation and founder and medical director of the Hospital for Special Surgery (HSS) Lifestyle Medicine program at the HSS and Weill Cornell Medicine in New York City, presented the findings.
The retrospective cohort study included patients who had primary hip or knee replacement surgery at Weill Cornell and participated in the "intensive" or "selective" track of the LSM program from March 1, 2022, to September 15, 2024.
Mandatory Referrals
Patients were referred to the program by orthopedic surgeons who had agreed as a group to refer patients if they had a BMI > 45 or had other chronic diseases, such as diabetes, requiring preoperative optimization.
Patients were then triaged with a scoring system "based on their willingness and confidence in change," Prather said. "About 77% choose the intensive program, which is the complete inverse of what we expected," she said. Those headed to surgery and not interested in the intensive program went into the selective group where they met one-on-one with an LSM provider and received written materials including information on the connection between lifestyle factors and joint replacements.
Those interested in the intensive program picked their goals and picked their clinical team, which might include a combination of behavioral health support, a smoking cessation expert, dietitian, physical therapist, or weight management expert, for example. They met one-on-one with providers as well as having care coordination and group programming.
Immediate surgical outcomes were collected from electronic health records and included length of stay, opioid use, ICU admission, 90-day readmissions, reoperations, infections, and persistent postoperative pain.
Fewer Infections and Pain
The study included 292 patients (154 in the intensive group and 138 in the selective arm). Compared with those in the selective group, those in the intensive group had fewer wound or surgical site infections (3% in the intensive group vs 9% in the selective; P = .047) at 90 days.
The intensive group also reported significantly less persistent pain postoperatively (10% vs 26%; P < .001). That's important, Prather said, "because 33% of people who receive a knee replacement surgery in the United States are unhappy with it. Maybe the answer is the host and not always the procedure."
Other postoperative outcomes were not significantly different and lengths of stay were not significantly different between the groups.
"This is proof of concept that we can mitigate health risks around the time of surgery by looking at 90-day outcomes," Prather said.
Infections Expensive for Hospitals
She said they chose knee and hip replacements because they are in a bundled payment model. "One infection, they lose a lot of money." Prather said. "So when you can show 90-day outcomes are improved, you save [health systems] money."
"OA [osteoarthritis] is linked to chronic, systemic inflammation [CSI] caused by modifiable social, environmental, and lifestyle factors," Prather said. "CSI creates gut dysbiosis, which increases painful, radiographic knee OA, independent of BMI or weight."
Most people in the US with OA (59%) have a metabolic phenotype. "It's not just 'I got old,'" Prather said. "It's metabolic disease." Chronic disease is linked to poorer outcomes, morbidity, and mortality following hip and knee replacements.
Applying an LSM intervention preoperatively to mitigate CSI was a logical step, she said.
Ajay Joseph, MD, a cardiologist and LSM specialist at the Saint Francis Heart and Vascular Institute in Tulsa, Oklahoma, who was not involved with the study, said the lower infection rate (3% in the intervention group vs 9% in the selective group) was particularly impressive because "HSS already has one of the lowest rates of infection, one of the biggest complications of orthopedic surgery. Using a nonpharmacological lifestyle medicine-focused holistic approach, they were able to decrease it even further, which is remarkable. This has significant implications for not just orthopedic surgery but for all kinds of surgery."
The next frontier, he said, would be conducting a cost-benefit analysis. "A program like this can certainly be replicated and expanded by board-certified lifestyle medicine providers at their hospitals," Joseph said.
This study was supported by the Simonson Family Foundation. The authors and Joseph reported no relevant financial relationships.
Marcia Frellick is a Chicago-based healthcare journalist and a regular contributor to Medscape Medical News.