Outcomes of Complex Reconstruction in the Elderly



Outcomes of Complex Reconstruction in the Elderly

Curriculum in Geriatrics for Orthopedic Specialists

Educator’s Guide

Charles N. Cornell, MD

Professor of Clinical Orthopedic Surgery

Hospital for Special Surgery

Weill College of Medicine of Cornell University

Title Slide: No commentary

Slide 2: The 2000 population census confirmed that the predicted graying of the US population is occurring. The evolving demographics of our society will have an important impact on the practice of Orthopedic Surgery and related musculoskeletal specialties. By the year 2040 20% of the population or approximately 77.2 million citizens will be older than 65 years of age. The current estimate of the demand for joint replacement surgery in citizens older than 65 is 15 per 10,000. In the year 2000 approximately 500,000 total knees were performed and 375,000 hip fractures were repaired. With the projected growth of the elderly population the demand for these procedures will increase seven fold. This projects that 3.5 million citizens will seek total knee replacement in 2040. These developments will require a shift in the focus of the orthopedic workforce as well as efforts to improve the delivery of care to the elderly population.

Slide 3: Of additional interest is the fact that the oldest segment of the population is the part expanding most rapidly. It is estimated that by 2040 the over 85 year old population will double in size to 3% of the overall population. Results of surgical intervention in this population is largely uncharted territory. However, recent studies are gradually revealing guidelines and principles for treatment of this age group. The purpose of this presentation is to review the most current results of reconstructive surgery in this age group and to suggest general principles in approaching the elderly patient that needs reconstructive surgery.

Slide 4: Much of what has been learned in the care of the elderly patient has been gained from the study of surgical outcomes of fractures of the hip over the past twenty years. Through this study a new paradigm for the approach to care and the evaluation of outcomes has emerged. Traditional reports of hip fracture treatment focused largely on surgical aspects of care and emphasized traditional wisdom. It was widely held, for instance that preservation of the femoral head was the most desirable outcome of treatment as it seemed logical that in the absence of visible arthritic change the patients own femoral head would be a better bearing than any artificial or metallic prosthetic replacement. Most of the studies approached the hip fracture population as a homogeneous one and stratified outcomes according to age and sex. Since then, clear evidence has emerged that the most important predictor of outcome in the elderly hip fracture patient is pre-injury over all health status. Evidence clearly emerged that suggested that series of hip fracture patients should be stratified according to pre-injury health status and that the choice of surgical procedure should largely be based on this stratification.

Slide 5: Past and recent studies all conclude that although overall mortality has improved there is an increased risk of mortality during the first year after hip fracture. This mortality rate ranges from 12 – 25%. Of interest is that for those that survive the first year mortality predictably returns to that of the age-matched general population and that after the first year the five year predicted survival is 50%. There appears to be two clear groups: those that die within the first year and those that recover and experience a life expectancy similar to aged match citizens that haven’t sustained a hip fracture. The best predictor for which group a patient will fall is their overall pre-fracture health status.

Slide 6: This new understanding has helped to clarify what was considered contradictory findings of past studies. For instance, it was clearly observed that the outcome of hip fracture surgery could be predicted from the nutritional status of patients on admission. In our own experience one-third of our patients admitted with hip fractures had clear evidence of acute and chronic protein malnutrition, and that this group of patients predictably suffered more complications and an increased risk of one year mortality. Our data clearly demonstrates two populations: one group was malnourished while the other wasn’t. Of great frustration, however, has been the disappointing observation that nutritional supplementation fails to alter the outcomes in these two populations. More recent studies demonstrate that nutritional deficiency by itself is not a predictor of outcome but is associated with poorer overall health status and physical function both of which can act as independent predictors of outcome. Analyzing our hip fracture population for nutritional status revealed that it is an element of overall health status and that it suggests that approximately one-third of our patients present with poor overall health and suffer poor outcomes of treatment. It is now clear that elderly populations of patients are not homogeneous but should be categorized as falling into a fit versus an un-fit group. Nutritional status in fact can serve as an indicator of pre-injury fitness.

Slide 7 and 8: In the elderly it is clear that fitness cannot be judged by chronological age. Rather fitness is judged based on several factors. Fit elderly patients have fewer than three medical comorbidities, are competent community ambulators, routinely engage in sports or other social activity and participate in the management of their social and financial affairs.

Slide 9-11: Recent studies analyzing outcomes of hip fracture care have now demonstrated that the hip fracture population is not homogeneous. Surgical management should take into account the “Fitness” of the patient and not just the chronological age or fracture classification. The two procedures felt to be the gold standard for displaced femoral neck fractures ( closed pinning and hemiarthroplasty) have now been demonstrated to carry a higher risk of need for re-operations and ultimately higher morbidity and cost than total hip replacement in the active and “fit” elderly patient. Prospective, randomized studies by Blomfeld et al have now documented that for patients with displaced femoral neck fractures total hip replacement, which was traditionally considered “overkill” is actually the ideal procedure. Compared to hip pinning and partial hip replacement, THR patients undergo fewer revisions surgeries, have better function and better overall perceived health status. The fitter or more active the patient the greater the advantage for THR.

Slide 12: This experience points out that the elderly need surgical procedures that minimize the risk of re-operation, result in excellent pain relief and restore anatomy sufficiently to permit excellent return of function and ambulation.

Slide 13: This approach has led to a new evidenced based algorithm for treatment of femoral neck fractures in the elderly. Non displaced fractures are treated by pinning in-situ in both fit and unfit patients as the results of this procedure are excellent. For displaced fractures fit elderly patients are best treated with THR. Unfit patients, typically the nursing home patient or those limited to household ambulation can be most safely treated by hemiarthroplasty.

Slide 14: The principles outlined above also pertain to total joint arthroplasty in the elderly population. The demand for arthroplasty in the oldest portion of the population is growing rapidly. Among nonagenarians the demand for total hip replacement is approximately 136 per 10,000 population. In 1995 33,000 were performed in the USA. The perioperative mortality was 2.3%

Slide 15: There are several reported studies examining the outcome of total joint replacement in this oldest population. Berend et al reviewed their experience with hip and knee replacement and found a higher incidence of post-op complications and longer hospital stays but low perioperative mortality and excellent outcomes. L’Insalata examined results for TKR in the above 80 population and had similar findings. Shah et al looked specifically at frail elderly patients undergoing THR and found excellent outcomes with low mortality. Several key findngs are consistent with these three studies:

1. Elderly patients with adequate preparation can safely undergo arthroplasty and achieve improvements in hip and knee scores that are comparable to younger patients.

2. There is an increased risk of perioperative complication most commonly including post-op delirium, pneumonia, UTI’s and decubitus ulcers.

3. Aseptic loosening did not occur in any of these series suggesting that these prostheses outlive the patients. This justifies the routine use of constrained prostheses in this population to reduce the risk of instability and dislocation.

4. In spite of the higher risk of morbidity, perioperative mortality was low and the successful elimination of pain and restoration of mobility justifies the procedures.

Slide 16 and 17: These two slides illustrate the value of joint replacement in the elderly. Slide 16 plots median NHP component scores which are an assessment of overall health status assessing multiple domains. The bar plots indicate scores pre-operatively in elderly patients with OA of the knee and compares these to various times of followup. The line drawn across the graph depicts the scores for a control population of similar age but without OA. Higher scores indicate poorer health. Total knee replacement clearly restores NHP scores into the range of the normal population by 12 months after surgery. The figure on slide 17 plots the percent survival of a cohort of 90 y.o. recipients of an arthroplasty as a function of time since the arthroplasty and compares this to a control population of similar age that haven’t undergone arthroplasty. The 90 y.o. patients treated with arthroplasty appear to have better survival over the period of observation.

Slide 18: General principles for arthroplasty in the elderly are reviewed in this slide. As reported the incidence of aseptic loosening is essentially zero in this age group. Constrained components prevent dislocation in THR and constrained TKR components help avoid pain and instability in TKR’s. Their use should be encouraged in primary arthroplasties in elderly patients. Additionally, Berend et al attempted to perform bilateral procedures during the same anesthesia in their elderly patients but observed an unacceptable complication rate and currently recommend against this approach.

Slides 19 and 20: These radiographs illustrate the approach to staged bilateral THR in a “fit” 94 y.o. female with severe OA of both hips. She was treated with THR’s staged 6 months apart. Constrained acetabular components were used. At 2 years of followup the patient continues to live independently with her spouse and is unimpeded by hip function.

Slides 21 and 22: These radiographs illustrate a failed THR in a “ fit “ 88 y.o. retired chemical engineer. He underwent revision of both components and a contained acetabular component was used to avoid the risk of post-op dislocation. The patient recovered without complication and returned the following year for a primary THR of the right hip.

Slide 23: Summary Bullet Points

References

1. Berend, M.E., Thong, A.E., Faris, G.W., Newbern, G., Pierson, J.L., Ritter, M.A.: Total Joint Arthroplasty in the Extreme Elderly. J Arthroplasty 2003; 18: 817- 821

2. Birdsall, P.D., Hayes, J.H., Cleary, R., Pinder, I.M., Moran, C.G., Sher, J.L.: Health Outcome after Total Knee Replacement in the Very Elderly. J Bone and Joint Surg 1999; 81B: 660-662

3. Blofeldt, R., Tornkvist, H., Ponzer, S., Soderqvist, A., Tidermark, J.: Comparison of Internal Fixation with Total Hip Replacment for Displaced Femoral Neck Fractures. J Bone Joint Surg 2005; 87A; 1680-1688

4. Kreder, H., Berry, G.K., McMurtry, I., Halman, S.I.: Arthroplasty in the Octogenarian. J Arthroplasty 2005; 20: 289-293

5. L’Insalata, J., Stern, S.H., Insall, J.N.: Total Knee Arthroplasty in Elderly Patients. J Arthroplasty 1992; 7: 261-266

6. Shah, A.K., Celestin, J., Parks, M., Levy, R.: Long Term Results of Total Joint Arthroplasty Patients who are Frail. CORR 2004; 425: 106-109

Pre and Post Test Questions

1. As the demographics of the US population ages the demand for joint replacement has risen. Many factors influence the overall success of these procedures as well as the risk of complications. However, the best predictor of overall post-operative

outcome is:

A. Patient Age

B. Gender

C. Baseline health status and fitness

D. Pre-existing cardiovascular disease

E. Serum Albumin level of 3.5 mg/dl or less

The best predictor of success and outcome is the overall preinjury assessment of health and fitness. Although age and gender are associated with perioperative risk the preinjury overall health status is the best predictor of outcome.

2. Although elderly patients experience a higher risk of perioperative complications compared to younger patients overall in hospital mortality is low. The most common complications following total joint replacement in the elderly include all of the following except:

A. Pneumonia

B. Delerium

C. Decubitus ulceration

D. Urinary tract infection

E. Aseptic component loosening

Common post-op complications in the elderly include a higher incidence of pneumonia, UTI and decubitus ulceration. Delerium is possibly the most common post-op complication seen in this population of patients. Aseptic loosening is not reported in most case series of elderly joint replacement patients.

3. With respect to total joint replacement in the elderly, the following statements are true except:

A. Total knee replacement will significantly raise health related quality of life assessments in most elderly patients suffering from severe osteoarthritis.

B. Elderly patients are at higher risk for venous thromboembolism and require more aggressive DVT prophylaxis than younger patients.

C. Delerium occurs frequently but usually resolves to baseline mental status after the acute post-operative period.

D. Elderly patients with severe bilateral disease are best served by performing simultaneous bilateral arthroplasties under a single anesthesia.

E. The demand for total knee replacement is roughly double that for total hip replacement.

Total knee replacement has been shown to raise nearly all health related quality of life assessments and some studies suggest that successful joint replacement can increase life expectancy. Elderly patients are at greater risk of DVT and Pulmonary embolism than younger counterparts and more aggressive prophylaxis( i.e. warfarin/LMWH as opposed to aspirirn) is required. Delerium occurs commonly but is usually transient and mental status can be expected to return to baseline after the acute post-op period. Total knee replacement is currently performed with twice the frequency of total hip replacement. The incorrect answer is D. The incidence of severe perioperative complications when simultaneous bilateral arthroplasties is performed in the elderly is prohibitive and staged procedures should be planned.

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