Total hip arthroplasty (THA) and total knee arthroplasty (TKA) have proven to be effective procedures to relieve the pain and disability associated with severe arthritis.2 The satisfactory outcomes of these surgeries in restoring function and quality of life have led to the observed large number of these operations done during the past 20 years.
The most rapidly growing segment of the population of the United States currently is the age group older than 80 years.1 It is estimated that from 1–3% of the population older than 65 years eventually will require a hip or knee replacement.19 With the increasing age of the population, the incidence and clinical consequences of arthritis likewise are having a greater impact on society, especially in the sector of the population living into the eighth and ninth decades.6 This environment has left the orthopaedic surgeon faced with two subsets of the geriatric population, the younger-elderly and the frail-elderly. This second subset is not only more challenging to treat, it also is a group rapidly increasing to previously unimagined levels.
These frail, older persons typically are 80 years or older and have combined clinical, behavioral, and social comorbidities. These patients have diseases in multiple organ systems that can be worsened by operative intervention or can limit the patient’s ability to participate effectively in postsurgical rehabilitation.13 Sometimes decisional capacity has been lost and surrogate decision-makers are required.7 In this setting, the orthopaedic surgeon often functions as a member of a multidisciplinary team of internists, geriatricians, family physicians, social workers, and various therapists. Prior studies of the surgical results and outcomes of THAs or TKAs done on elderly persons generally have shown satisfactory results although with specific increased complications.8,12,20 One study includes a wide spectrum of geriatric patients ranging from relative healthy and otherwise vigorous younger-elderly to smaller numbers of much older patients with many comorbid problems, in addition to an arthritic hip or knee.14 It is unclear, however, how results of joint replacements in the group of elderly patients who are frail and who presented with disabling hip or knee pain that had not responded to nonsurgical treatments compare with otherwise well-established successes of joint replacement. To elucidate outcomes of THAs and TKAs done in this specific patient subset of elderly patients who are frail, we reviewed our results for subjective patient satisfaction, postoperative ambulatory function, and perioperative mortality and morbidity.
MATERIALS AND METHODS
Between 1990 and 2000, 130 total joint replacements were done among 126 patients older than 80 years at the time of surgery. The senior author did all the surgeries and followed up all the patients. This represented 4.5% (130 of 2875) of all the total joint arthroplasties done by the senior author during this period; the remaining 2745 joint replacements were done in patients younger than 80 years. Hospital and outpatient charts and preoperative and postoperative radiographs at regular followup intervals were available for retrospective review. Of the 126 patients, medical records for 30 patients were not available, leaving 96 patients older than 80 years. All of these patients had a minimum followup of 2 years. In this group, 100 primary joint replacements were done: 70 primary THAs and 30 primary TKAs.
Four patients had bilateral knee surgeries (Table 1). For each patient, health outcomes assessments included patient-related measures to determine psychologic pain and disability and the societal impact of the procedure. All data and information were collected in accordance with institutional review board guidelines and approval. A previously accepted protocol was followed.9
The average age at the time of initial elective surgery for these patients was 85 years (range, 80–99 years). The average length of followup was 6 years (71.3 months) (range, 12–130 months). The length of hospital stay gradually decreased throughout the decade of this study from approximately 9 days before 1995 to 5 days after 1995. The female to male ratio was 2–1.
The patients’ hospital course, clinical comorbidity, preoperative and postoperative ambulatory status, 6-month mortality, early and late major surgical complications, including infection, dislocation, and mechanical loosening, DVT prophylaxis, and disposition, were reviewed. The patients’ own subjective evaluations of the procedure outcome were recorded as a grade of very satisfied, satisfactory, or poor. The societal impact of the procedure was evaluated by recording each patient’s ultimate level of independent living compared with before surgery.
The major indication for primary joint arthroplasty in each of the elderly patients was pain and decreased ability to function independently. The specific diagnoses were osteoarthritis (88%), posttraumatic arthritis (6%), RA (3%), ON (2%), and pathologic fracture (1%). Twenty-one percent (20 of 96) of the patients had significant and relatively disabling involvement of either the opposite hip or knee at the time of the initial index procedure. All the knee components and the femoral stems were cemented.
Anticoagulation therapy with Coumadin (Bristol-Meyers-Squibb; New York, NY) or aspirin was begun the night of surgery and was continued after discharge from the hospital for a 6-week course. Sequential compression boots were used in conjunction with pharmacologic agents during the hospital stay. All patients who had TKA used a continuous passive motion (CPM) machine during the immediate postoperative period. All patients who had THA were treated with an abduction pillow postoperatively. Supervised therapy for sitting, standing, and walking with weightbearing as tolerated was started on postoperative day 1 for all patients and was continued during the recovery period.
An internist and anesthesiologist evaluated every patient preoperatively. All patients had significant medical comorbidities and were assigned to American Society of Anesthesiologists (ASA) Level III or IV.4 All patients in the elderly group had associated hypertension (70%) or cardiac disease (30%). The remainder of the secondary clinical comorbidities included diabetes mellitus (15%), Alzheimer’s disease (5%), Parkinson’s disease (2%), renal failure (2%), metastatic disease (1%), and cirrhosis (1%).
Ninety-five percent (92 of 96) of the patients selected the highest subjective evaluation for the results of the operation, very satisfied. The remaining 5% (four of 96) of the patients considered the results of the operation satisfactory. No patients considered their outcome poor. Most patients who were not very satisfied involved those with complications from morbidity.
The discharge disposition of the 96 patients was to a rehabilitative facility (45%), home (35%), or nursing home (20%). Every patient used an assistive device (cane or walker) for community ambulation preoperatively. Within 1 year after surgery, 90% (86 of 96) of the patients became community walkers without the need for assistance. Within the same time, 70% (11 of 15) of patients who were household ambulators preoperatively became community walkers postoperatively. At long-term followup of as many as 5 years, 88% (84 of 96) maintained community ambulation. Of this group, 78 were community walkers on their own, and six could leave the house accompanied by another person. The remaining 12% (12 of 96) could walk in the house for usual tasks but could not shop or travel easily, even with assistance.
A review of the mortality and morbidity after surgery showed that no patient died of the operation or in the first 6 months after surgery. Causes of morbidity included two infections, one dislocation, and one leg-length discrepancy. Both infections were recognized early in the immediate postoperative period, and the patients were treated successfully with irrigation and debridement, component retention, and intravenous antibiotics tailored to the cultured organism. The only patient with a dislocation was treated with an abduction brace. A leg-length discrepancy of 3 cm was addressed with a shoe lift and the patient returned to community ambulation. There was no documented case of early or late mechanical loosening. Approximately 5% of the patients had mild mental confusion for several days after surgery, all of which cleared rapidly.
Twenty-six patients had TKAs, of which four patients had bilateral replacements. Of the 30 primary TKAs done, the mean postoperative range of flexion in patients was 112°, with a range from 90°–130°. At long-term followup (5 years), a flexion contracture greater than 5° was observed in only one patient.
Twenty patients had substantial pain and disability in another weightbearing joint before the initial joint arthroplasty. Of this group, 5% (four of 20) ultimately had another successful joint replacement in the ensuing years. The remaining patients had an adequate decrease in symptoms, therefore additional surgery was not necessary.
The graying of America will greatly affect the practice of orthopaedics during the next 2 decades. Consequently, orthopaedists must prepare for more aging patients. With 20% of the United States population expected to be 65 years and older by the year 2030, bone and joint disease will be included among the top areas of concern for this age group and for the healthcare community in general. According to the United States Census Bureau, the percentage of Americans older than 65 years is expected to increase from 12.6% of the total population today to 20% by 2030.1 The high incidence of OA is expected to increase dramatically. In 2001 the Centers for Disease Control projected that by 2020, 60 million Americans would be affected by arthritis. This is 20% of the population.1 This aging population will need orthopaedists to help restore their loss of mobility, heal their aching joints, and return them to a satisfying and active lifestyle.3
The reality of an aging America is complicated by the fact that the orthopaedic surgeon is faced with a geriatric population that can be divided into two groups: the younger-elderly and the frail-elderly. The latter group is more challenging to treat, and is a subset that is growing quickly. These frail-elderly represent the portion of the geriatric population 80 years or older who often have diseases in multiple organ systems that can be exacerbated easily by surgical intervention or that inhibit the patient’s ability to effectively participate in postsurgical rehabilitation.16 These frail, older persons typically have combined clinical, behavioral, and social comorbidities. Often decisional capacity has been lost and surrogate decision-makers and family members are needed. In this environment, the orthopaedic surgeon often functions best as a member of a team of social workers, geriatricians, family physicians, internists, and various therapists.
In this group of frail elderly, 95% of patients recorded a high degree of satisfaction with the results of the joint replacement. This coincides closely with the high patient satisfaction usually observed in patients of younger age who have the same procedure done.15 All patients used some form of assistive device for walking before surgery. After surgery, 90% of the patients became community walkers without assistive support. Seventy percent of patients who were household ambulators preoperatively became community walkers postoperatively. Furthermore, the joint replacement was effective in maintaining an independent quality of life. Ninety-seven percent of this group of elderly patients was able to continue either to live alone or live with help of a family member or aide. Before surgery, it was this level of independence that was typically in jeopardy because of the problems imposed by the involved joint.
There were no deaths from surgery in the perioperative period or the first 6 months after surgery. This 0% mortality rate is unusual, and contrasts significantly to prior published mortality rates ranging from 0.9–28% in a similar group of patients.11 We attribute this favorable result to careful preoperative screening by the primary physician and continued monitoring of the patient by the internist in the postoperative period; however, it may be unrealistic to expect this rate to continue in a larger group. All patients had anesthesia administered by an experienced orthopaedic anesthesiologist. American Society of Anesthesiologists’ ratings correlate in a linear manner with complications after total joint replacement.21 In this preselected group of frail elderly patients, all patients were ASA III or IV and no statistical linear correlation could be established between preoperative comorbid disease and the incidence of medical complications reported after surgery. The most common postoperative medical complication observed was confusion. Although one cause could not be identified, this may be attributable to problems with fluid balance, release of intramedullary fat and marrow into the general circulation, or underlying atherosclerotic cerebrovascular disease, all of which have more severe effects in the older patients with limited reserves.10 This contrasts favorably with a 14–22% incidence reported elsewhere for patients with generally comparable comorbidities.5
Complications occurred in this group. Causes of morbidity involved two infections, one dislocation, and one leg-length discrepancy. Both infections were recognized early in the immediate postoperative period and the patients were treated successfully with irrigation and debridement, component retention, and intravenous antibiotics specific to the cultured organism. The only patient with a dislocation was treated with an abduction brace. A leg-length discrepancy of 3 cm was addressed with a shoe lift and the patient returned to community ambulation. There was no documented case of early or late mechanical loosening.
Our results are limited by the retrospective design of the study. More meaningful data would be garnered by a controlled prospective investigation with controls matched to the frail-elderly counterparts. Additionally, there is a clear limitation in any subjective assessment of outcomes and our generic assignment of very satisfied, satisfied, or poor limits nuances in patient perceptions to three broad categories. Nevertheless, our retrospective analysis provides insight into the successful outcomes of hip and knee replacements in a group of high-risk surgical patients.
The primary goal of hip replacement in elderly patients is to improve the quality of life and relief of pain. Taylor17 estimated that for patients older than 60 years, a 10–1 monetary benefit exists after THA and a 2–1 monetary benefit exists after retirement age. This is based on the capture of lost earnings before retirement.17 In addition, the average annual cost of nursing home care in urban Northeastern United States areas is an estimated $50,000 to $60,000.17 Ninety-seven percent of patients in this series were able to maintain their preoperative level of independence, which had been jeopardized by the painful arthritic joint, and only 5% required placement in a nursing home. We suggest there is high cost effectiveness in total joint replacement in elderly patients if one can assume that the patients would have required admission to an institution if surgery were not done.18 Many orthopaedic surgeons will agree that treating elderly patients can be challenging. Elderly patients who are frail will form a larger portion of orthopaedic practice in the future and demand more service than ever. This study specifically addresses the outcomes of total joint replacement in the elderly patients who are frail. A satisfactory and cost-effective health outcome can be anticipated after total joint arthroplasty in this age group.
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