Total hip replacement in patients aged 80 years and older

Difference in the degree of improvement in patient-reported outcomes after total knee arthroplasty between octogenarians and sexagenarians: a propensity score matching analysis

BACKGROUND

As the population ages, the use of primary total knee arthroplasty (TKA) is on the rise in the octogenarian population.

AIMS

The objective of this study was to compare patient-reported outcomes after TKA in octogenarians versus sexagenarians.

METHODS

This retrospective case-controlled comparative study with a propensity score matching analysis was conducted by 251 patients who underwent TKA for degenerative osteoarthritis of the knee. After the propensity score matching analysis, 38 octogenarians and 41 sexagenarians were identified. Range of motion (ROM), degree of flexion contracture, Charlson Comorbidity Index score, Knee Society score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, the 36-Item Short-Form Health Survey (SF-36), postoperative complications, length of stay, and 90-day mortality after TKA were compared. The degree of improvement of each functional parameter was also assessed.

RESULTS

There was no significant difference in the degree of improvement in postoperative ROM, flexion contracture, or KSS. There were only significant differences in length of hospital stay and volume of blood transfusion (p < 0.001 and p = 0.004, respectively). The octogenarian patient group showed significantly inferior outcomes for WOMAC and SF-36 score compared to the sexagenarian patient group (p = 0.009 and p = 0.022, respectively).

CONCLUSION

Although the functional improvements after TKA were excellent regardless of age, TKA seemed to contribute little to quality of life in octogenarian patients. Therefore, a careful approach to improving satisfaction with subjective outcomes is needed for octogenarian patients who undergo TKA.

Primary collared uncemented total hip arthroplasties in the elderly: a safe and reliable treatment option

The age of patients undergoing primary Total Hip Arthroplasty (THA) remains fairly constant despite an increasingly elderly population, possibly owing to concern over postoperative complications. This study evaluated 90-day outcomes in patients over 80, undergoing uncemented collared primary THA for osteoarthritis in a high volume unit. Data were recorded from 153 consecutive patients. There were 0.65% mortality rate and 1.3% major systemic complication rate. American Society of Anesthesiologist (ASA) grade was an independent predictor of inpatient complications. Mean preoperative and 90-day postoperative Oxford Hip Score was 24 and 46 respectively. No radiological evidence of femoral stem migration was seen. Our cohort shows low morbidity and mortality rates. ASA not age helps predict inpatient complications. Uncemented collared femoral prosthesis resulted in excellent functional and radiological outcomes.

Perioperative complications following total joint replacement

Total joint arthroplasty is a safe and highly effective treatment for moderate to severe osteoarthritic symptoms and other causes of joint derangement in the elderly population. Significant improvements in pain, function, and quality of life are nearly universal, with a low rate of complications and adverse outcomes. Because of its success and cost-effectiveness, the rate of utilization of TJR is increasing, and all health care providers must be familiar with the potential complications and perioperative management of these patients. Elderly patients may be at a higher risk for postoperative medical complications; however, the majority of these complications are minor and many are avoidable with appropriate preoperative screening and careful postoperative management. As with all patients undergoing TJR, patients should be prophylactically treated for infection and thromboembolism and carefully followed for the development of these potential complications as well as fracture, hip dislocation, and neurovascular dysfunction. Postoperative delirium may be minimized and prophylactically treated in appropriate elderly patients to maximize recovery and promote safety.

Hip replacement in the very elderly: selecting a suitable candidate

The selection of a suitable candidate for hip arthroplasty involves several important patient-specific considerations. Advanced age may be considered a relative contraindication for elective surgery, and may unfortunately cause a stereotypical dismissal of very elderly patients with a painful hip. However, several studies have demonstrated the exceptional safety and symptomatic benefits of hip arthroplasty in octogenarians and nonagenarians when appropriate medical precautions and preparations are utilized. The very elderly present specific social and medical scenarios that must be identified to establish an accurate risk assessment and achieve an optimal postoperative result. Although a greater likelihood of perioperative complications exists, the very elderly can expect to achieve highly significant pain relief and functional improvement after hip replacement. Future studies will focus on improvements in outcomes after hip replacement that may be realized with new advances in postoperative protocols.

The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more

Primary arthroplasty may be denied to very elderly patients based upon the perceived outcome and risks associated with surgery. This prospective study compared the outcome, complications, and mortality of total hip (TKR) and total knee replacement (TKR) in a prospectively selected group of patients aged ≥ 80 years with that of a control group aged between 65 and 74 years. There were 171 and 495 THRs and 185 and 492 TKRs performed in the older and control groups, respectively. No significant difference was observed in the mean improvement of Oxford hip and knee scores between the groups at 12 months (0.98, (95% confidence interval (CI) −0.66 to 2.95), p = 0.34 and 1.15 (95% CI −0.65 to 2.94), p = 0.16, respectively). The control group had a significantly (p = 0.02 and p = 0.04, respectively) greater improvement in the physical well being component of their SF-12 score, but the older group was more satisfied with their THR (p = 0.047). The older group had a longer hospital stay for both THR (5.9 versus 9.0 days, p < 0.0001) and TKR (6.2 versus 8.3 days, p < 0.0001). The rates of post-operative complications and mortality were increased in the older group.

Total joint replacement in the elderly patient

Osteoarthritis of the hip and knee is extremely common in the growing elderly population. Total joint replacement (TJR) of the hip and knee are extremely effective procedures, resulting in decreased pain and improved function and quality of life in patients of all age groups including the elderly. The prevalence and use of TJR is increasing at a significant rate, therefore increased awareness of perioperative issues following TJR among health care providers is of paramount importance. Although elderly patients may be slightly more susceptible to perioperative complications, long-term success rates remain high, and careful perioperative monitoring and preventative measures have resulted in high rates of patient safety and few adverse outcomes in the elderly.

One- versus two-stage bilateral total hip arthroplasty

We compared the results of 1-stage uncemented bilateral total hip arthroplasty (THA) performed in 49 patients (98 hips) with those of 2-stage uncemented bilateral THA performed during the same hospital stay in 40 patients (80 hips). There was no significant difference in mean Harris Hip Score preoperatively and at final follow-up between the 2 groups. Radiographic evaluation of patients in the 1-stage group revealed the acetabular component was stable in 95 hips and possibly unstable in 3. The femoral component was bone-ingrown in 91 hips and stable fibrous in 7. In the 2-stage group, the acetabular component was stable in 77 hips and possibly unstable in 3. The femoral component was bone-ingrown in 71 hips and stable fibrous in 9. In both groups, no patients exhibited clear signs of loosening, migration or osteolysis.In the 1-stage group, postoperative dislocation occurred in 2 hips and 1 patient had developed deep venous thrombosis and pulmonary embolism. In the 2-stage group, no complications were observed. The incidence of complications was not significantly different between the 2 groups.There was no significant difference in the total blood loss and mean hemoglobin level preoperatively and at discharge between the 2 groups. However, in the 1-stage group, operative time, intraoperative blood loss, procedure cost, and hospital stay were significantly reduced compared with the 2-stage group. Therefore, 1-stage bilateral THA is a safe and effective option for patients with significant arthritic disease of both hips.

Total hip arthroplasty revision in elderly people with cement and Burch-Schneider anti-protrusio cage

Total hip arthroplasty revision is increasingly becoming a common procedure, but the acetabular bone loss and the advanced age of the patients make revision procedures extremely complex and technically demanding. The aim of the present work is to examine the clinical and radiological results of the Burch-Schneider anti-protrusio cage (APC) implanted in revision hip arthroplasty with severe acetabular bone deficiency in elderly people. Between February 1994 and November 2005, a total of 60 revision operations of acetabular components were performed in 60 select patients (42 females and 18 males), using the Burch-Schneider APC. The indication for the Burch-Schneider APC use was massive pelvic bone loss with migration of the prosthesis cup and high-grade acetabular defects (type III or IV AAOS). The mean age at the time of surgery was 82 years (range 78-85 years). Polymethylmetacrylate cement (PMMA) was used to fill bony deficiencies in all the procedures. No graft was used. The average Harris Hip Score had improved from 28.2 preoperatively to 82.5 points at the time of follow-up. According to the classification of Gill et al., we have seen no Burch-Schneider cages definitely loose or probably. Only one acetabular component has been revised (for recurrent dislocation). Acetabular reconstruction with the use of cement and an acetabular support ring appears to have a useful role in the treatment of severe acetabular bony deficiency in elderly patients and may provide a definitive reconstruction.

Dislocation of primary THA done through a posterolateral approach in the elderly

We assess the rate of dislocation of total hip arthroplasty (THA) through a posterolateral approach in elderly patients and determine if this complication can be minimized. We retrospectively reviewed 150 THAs done between 1992 and 2002, through a posterolateral approach in patients 80 years and older. A hybrid THA was done in 46% of patients and both components were cemented in 54% of patients. A 28-mm head was used in 83% of the patients and a 32-mm head was used in 17% of patients. An elevated liner, with the elevation placed posteriorly, was used in 38% of hybrid cases. Starting in mid-1998, the posterior capsule was preserved and repaired at the time of wound closure (n = 77, 51%). Dislocation occurred in eight hips (five recurrent) at an average time to dislocation of 26.9 months (range, 1-79 months). No dislocations occurred when using a 32-mm head or a 28-mm head with a lipped liner in association with repair of the posterior capsule. Statistical regression analysis indicated that capsular repair was the single most important predictive factor for dislocation. When using the posterolateral approach for THA in patients older than 80 years, we suggest using a 32-mm head in combination with posterior capsular repair to reduce the incidence of dislocation.

LEVEL OF EVIDENCE

Therapeutic study, Level III-1 (retrospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

Total joint arthroplasty in the extremely elderly: hip and knee arthroplasty after entering the 89th year of life

The goal of this study was to evaluate the complications and efficacy of total joint arthroplasty in the extremely elderly and compare the survival with the normal age-matched population. One hundred one joint arthroplasties (45 total knee arthroplasties [TKAs], 56 total hip arthroplasties [THAs]) were performed in 83 patients 89 years old and older. Over an average follow-up period of 2.5 years, 26 (31%) of the patients died. Three patients (3.6%) died within the first 2 months' postoperatively. The perioperative medical complication rate (excluding deaths) was 14%. Significant improvements were noted in pain scores, Harris Hip Scores, and Knee Society Scores. The survival of patients in their nineties who undergo total joint arthroplasty is at least equal to the survival of an age-matched population for 2.5 years following surgery. With careful patient selection and patient care to minimize medical complications, total joint arthroplasty can be an excellent option for patients who are age 89 and older.

Primary and revision total hip arthroplasty for patients 90 years of age and older

OBJECTIVE

To assess the reliability, durability, and safety of primary and revision total hip arthroplasty (THA) in patients 90 years of age and older.

PATIENTS AND METHODS

Between 1970 and 1997, 66 THAs, 48 primary and 18 revision, were done for 65 patients aged 90 to 104 years (mean, 92 years). The Harris hip score was used to assess hip pain and function.

RESULTS

Patients were evaluated for pain, function, and satisfaction at a mean of 3.2 years after the THA. The Harris hip scores improved significantly (P = .004) for both primary and revision groups: from preoperative mean scores of 39 and 45 points to follow-up scores of 80 and 75 points, respectively. Two patients died in the early postoperative period of causes related to the operation. Thirty-seven other patients were dead at last follow-up and had lived a mean +/- SD of 6 +/- 2.2 years after the primary THA and 4.2 +/- 2.8 years after the revision THA. No hips required subsequent revision.

CONCLUSION

Total hip replacement was reliable, durable, and safe in this study group. Primary care physicians and surgeons should be aware that both primary and revision total hip replacement can be done safely and effectively in patients aged 90 years and older and can result in years of relief of pain and functional improvement.

One-stage bilateral total hip arthroplasty in patients > or = 75 years

Since 1991, 43 one-stage sequential bilateral total hip arthroplasties (THAs) inpatients > or = 75 years have been performed by the authors. The results were assessed to determine whether thiss procedure can be performed safely and with good outcome in this subset of patients. These results were compared to those of 1 36 patients < 75 years who underwent the same procedure. The one-stage bilateral procedure was performed in all patients who had signiificant arthritic disease of both hips. There was no diffference in length of surgery or length of hospital stay. Patients > or = 75 years were more likely to experience minor postoperative morbidity such as ileus and urinary tract infections. The incidence of myocardial ischemia was 2.3% in the elderly group With a mean follow-up of 2.5 years, 90% of the elderly patients lived independently, 80% walked without assistive devices, and 90% were pain free. Therefore, one-stage sequential bilateral THA is a safe and effective option for patients > or = 75 years when pain and functional limitations affect quality of life.

Long-term survivorship of cemented all-polyethylene acetabular components in patients > 75 years of age

Between 1974 and 1982, 132 consecutive hips in 112 patients >75 years of age were treated with primary total hip arthroplasty for osteoarthritis using a cemented all-polyethylene T28 socket and cemented T28 or TR28 stem with a 28-mm head size. At the time of review, 94 patients (110 hips [83%]) had died and 18 patients (22 hips [17%]) were still living (mean age at follow-up, 93 years). Five hips (5 patients) were lost to follow-up. Clinical follow-up averaged 8.9 years for the entire group and 14.6 years for patients still living. Only 2 acetabular components have been revised (1 for recurrent dislocation, 1 for infection). No acetabular component has required revision for aseptic loosening. Survivorship free of acetabular revision for aseptic loosening at 10 years was 100%; free of symptomatic acetabular loosening, 97.4% (95% confidence interval, 91.8-100%); and free of acetabular loosening, 95.9% (95% confidence interval, 89.7-100%). The commonest complication was postoperative hip dislocation, which occurred in 11 hips (8.7%) and which required reoperation in 2 hips. Cemented acetabular components implanted in patients >75 years of age with a diagnosis of osteoarthritis showed a high rate of survivorship free of revision and free of symptomatic aseptic loosening.

Revision hip surgery in the elderly: is it worthwhile?

We prospectively analyzed the outcome in 103 consecutive patients undergoing revision hip replacement, dividing the patients into 2 groups according to their age at the time of surgery. There were 45 patients aged 75 years or older and 58 patients aged younger than 75 years. The results of revision hip replacement in terms of pain relief, functional improvement, and patient satisfaction did not differ between the 2 groups. There was a significantly higher death rate among the elderly patients (13.3% versus 1.7%; P = .0202) and a significantly higher rate of dislocation (20% versus 1.7%; P = .0019). We conclude that revision hip replacement is an effective operation in the elderly, but that patient and surgeon must be aware of the risks that such surgery entails.

Revision of total hip arthroplasty in octogenarians

Twenty-seven revision total hip arthroplasties were performed in patients who were at least eighty years old. The average duration of follow-up was five years. There were no perioperative deaths, and only 11 per cent (three) of the patients had a major complication; all of the complications resolved. The only re-revision was the placement of an extended lip-liner for the treatment of recurrent dislocation. Of the twenty-five patients who were alive at the time of the most recent follow-up or who had been survived by a family member who could be interviewed, twenty-one (84 per cent) said that the operation had improved function, twenty-three (92 per cent) had less pain, and twenty-two (88 per cent) were satisfied with the result.

Total hip replacement in patients with osteoarthritis of the hip: improvement in pain and functional status

A simple, self-rating questionnaire was developed to assess the clinical outcome related to pain and function after total hip replacement surgery followed by physical therapy. Twenty-two patients, 57 to 86 years of age, with osteoarthritis of the hip who underwent total hip replacement surgery and received physical therapy following surgery, participated in the study. A questionnaire consisting of 11 items was developed to ascertain the level of pain, functional ability and the assistive ambulatory device used to perform selected activities of daily living. A maximum cumulative score of 55 points was possible. The functional categories monitored included: sitting, standing, sleeping, functional walking, distance walking, stair climbing, sitting/standing from a toilet seat, driving, and sexual activities. The questionnaires were completed preoperatively, and postoperatively at 3 and 6 months. The results showed an overall improvement of 56% at 3 months and 64% at 6 months after surgery. Twenty of 22 patients obtained "excellent" results with total hip replacement surgery and follow-up physical therapy. Results of this study indicated that total hip replacement followed by physical therapy decreases joint pain and improves function in patients with osteoarthritis of the hip.

Total knee arthroplasty in the octogenarian

Fifty consecutive Miller-Galante (Zimmer, Warsaw, IN) and Kinematic II (Howmedica, Rutherford, NJ) total knee arthroplasties for osteoarthritis in patients 80 years of age and over were compared to 50 arthroplasties in patients aged 65-69 years, with a minimum 2-year follow-up period. Each patient was assessed clinically using the Hospital for Special Surgery knee rating scores and radiographically by an independent observer. Average age of the study group participants was 83 years and of the comparison group, 68 years. Apart from age, the two groups were similar with respect to sex, bilaterality, prosthetic type, and preoperative Hospital for Special Surgery scores. No significant differences were noted for pain, functional level, strength, stability, or range of motion throughout the 2-year follow-up period. More octogenarian patients were found to have a preoperative deformity, and these deformities were larger, on average, than in the retiree group, suggesting a more advanced disease pathophysiology. A larger number of elderly patients required continued use of walking aids. An analysis of the cost-effectiveness data, collected for both groups, showed that although the in-hospital costs and length of stay were the same ($17,160 Can), the cost per patient after discharge was slightly greater ($2,00 Can) in the octogenarian. This prospective clinical study of total knee arthroplasties for osteoarthritis has shown that it is a reliable and cost-effective procedure for the octogenarian.

Osteoarthritis and rheumatoid arthritis in elderly patients. Differentiation and treatment

Osteoarthritis is differentiated from rheumatoid arthritis by age at onset, duration of morning stiffness, pattern of joint involvement, and radiographic findings. Distinguishing between the diseases can be challenging, because they have some symptoms in common. Therapy for osteoarthritis is aimed at relief of symptoms; treatment of active rheumatoid arthritis is more aggressive, aimed at controlling or modifying the disease. Both diseases may cause great pain and disability in elderly patients, so prompt diagnosis and treatment are essential.