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Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis.
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Abstract |
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Methods. Forty patients (46 THAs), aged 80 or older at the time of surgery, were identified for this study. Clinical assessment included amount of hip pain, limp, and use of assistive devices for ambulation at most recent follow-up. Radiographic assessment included implant stability, heterotopic bone formation, and osteolysis. Medical and hip-related complications, reoperations, and revisions were recorded from medical records.
Results. Eleven patients (27.5%) suffered a medical complication and six patients (15%) had a hip-related complication, all of which were treated and were not life threatening. Clinically, 80% were pain free and 70% walked without assistance at an average 4-year follow-up. Radiographically, all implants were stable without osteolysis. No components had been revised; however, four patients had undergone a reoperation, three for recurrent dislocation.
Conclusions. Elective total hip arthroplasty is a safe and effective treatment for end-stage osteoarthritis of the hip in the elderly patient. However, the procedure is not without risk. Complications, often related to preexisting comorbidities, do occur, but mortality rates are low.
TOTAL hip arthroplasty (THA) has been shown to be a safe and effective procedure for the treatment of patients with end-stage hip arthritis for the past four decades. The procedure is associated with low complication rates and significant improvements in comfort and functional status. (1). In addition, the procedure is considered cost effective (2). As a testament to the ability to decrease pain and improve function, over 100,000 such procedures are currently preformed annually in the United States (3).
Historically, most patients undergoing THA were in their sixties or seventies, with a more recent focus on the efficacy of the procedure in younger patients in their fifties or younger. Yet the most rapidly growing segment of the U.S. population is the age group older than 80 years (4). There are currently over 15 million people over the age of 80 years, and it is estimated that 1–3% of those older than the age of 65 will require hip replacement for relief of arthritic pain and disability (5,6). As a result, the number of patients over the age of 80 years needing hip replacement surgery is increasing. Issues related to elective THA in elderly people include higher incidence of medical and arthroplasty-related complications, increased mortality, functional outcome, life expectancy, and cost utility. Thus, the question is, How safe and effective is an elective THA for this age group?
The purpose of this study is (a) to report the clinical and radiographic results of a series of patients who were 80 years or older at the time of elective THA, and (2) to discuss the indications and contraindications specific to this population with regard to referral from the primary care physician to the orthopedic surgeon.
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Methods |
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Each patient's physical status was rated at the time of surgery according to the American Society of Anesthesiologists (ASA) physical status classification (7). Medical chart reviews were done to determine the length of hospital stay, comorbidities, and incidence and type (medical or hip related) of perioperative complications. Late complications were also noted. Most recent clinical and radiographic follow-ups were used to determine outcome. If a patient did not have current follow-up, he or she was contacted and asked to come in for clinical and radiographic reassessment. If the patient was unable or declined to return for complete assessment, a clinical assessment was completed by telephone with the patient or close relative. Clinical evaluation included assessment of hip pain, limp, and use of ambulatory aids. Radiographic evaluation included assessment of implant stability, heterotopic bone formation, and osteolysis according to accepted standards of assessment (8–10). The number of and reasons for any reoperations or revision procedures were recorded.
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Results |
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Of the 6 patients who had both hips replaced, 2 were done within the same hospitalization 1 week apart and the others ranged from 8 months to 3.5 years between procedures. Average length of hospitalization was 7.7 days (range 3–20 days), including the 12 and 15 days, respectively, for the 2 patients who underwent bilateral hip replacements during the same hospitalization. The average number of comorbidities was 2.2 (range 0–6). The most common medical conditions were hypertension in 24 patients and some form of heart disease in 20 patients. Physical status according to ASA classification at the time of each hip procedure was as follows: 1 ASA-1, 16 ASA-2, and 28 ASA-3. One patient's medical record was incomplete; therefore, ASA classification could not be determined.
Following surgery, 11 patients (27.5%) suffered a medical complication, none of which were life threatening. The most common postoperative complication was transient confusion in 5 patients. Other complications seen were single incidences of atrial fibrillation, gastrointestinal bleed, ileus, urinary tract infection, stable angina, chest pain (15 minutes duration with no electrocardiographic changes), mild dyspnea, and an ischial decubitus ulcer. Six patients (15%) had hip-related complications, including five cases of dislocation, and one each of infection/hematoma, heel ulcer, and peroneal nerve palsy.
At the time of completion of this follow-up study, 19 patients (47.5%) had died, including 2 patients who had bilateral hip arthroplasties. The average time to death was 63.5 months after hip replacement (range 1.8–140.3 months). Three patients died less than 2 years after the hip surgery, 1 during the perioperative or rehabilitation period. The perioperative death was secondary to sepsis from a chronic urinary tract infection and was not directly related to the hip surgery.
Average clinical follow-up was 47.5 months (range 1–127.6 months). Thirty-one patients were assessed by the surgeon in the clinic, and clinical assessment was done by telephone interview with the 9 other patients. Of the 46 hips, 37 caused no pain (80%). Four caused mild and five caused moderate pain. Twenty-eight patients walked without assistance (70%); 8 used a cane (4 as a result of the hip), 3 used a walker, and 1 was unable to walk.
Average radiographic follow-up was 38.9 months (range 1–127.6 months). All implants were radiographically stable at latest follow-up, with no evidence of osteolysis (Figure 1). Three hips showed evidence of heterotopic ossification, none of which was symptomatic. No patients had undergone component revision. Four patients had undergone reoperation. Two hips required conversion to a constrained liner to prevent recurrent dislocation, and 1 other patient had repositioning of the acetabular component with exchange of the polyethylene liner secondary to dislocation. One patient had a incision and drainage procedure secondary to wound dehiscence.
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Discussion |
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One of the major concerns with performing surgery in an elderly patient is the increased risk of complications, caused by an increasing prevalence of comorbidities that come with advancing age (11,12). The prevalence of comorbidities was evidenced by the ASA ratings in this patient group, with just 1 patient free of any systemic disease. Eleven patients experienced medical complications postoperatively, none of which resulted in mortality. This medical complication rate (27.5%) is similar to that in other elderly patients following elective THA. Keisu and colleagues (13), in a series of 114 elderly patients, reported a 24% rate of medical complications, and Brander and associates (14) found no difference in rate of medical complications between groups of patients aged 65 to 79 and those over the age of 80 who underwent either THA or total knee arthroplasty. Imamura and Black (15), in a study aimed at assessing the impact of comorbidities on surgical outcome, found that comorbidities were a significant determinant of serious complications following THA. However, they also found that the presence of comorbidities did not negatively influence functional outcome.
Certain arthroplasty-related complications may also be higher in elderly people. Woolson and Rahimtoola (16) reported a trend toward an increased incidence of dislocation with increasing age. Age alone may not be the critical factor, as other studies report increased rates of dislocation in female subjects (17–19) and in those with altered mental status postoperatively (20), and both of these factors are seen with greater frequency in the elderly patient undergoing elective THA. Dislocation rates in other studies of primary THA in patients over the age of 80 ranged from less than 1% to 15% (13,14,21–24). Three hips or patients (6.5%) in this study required a reoperation as a result of recurrent dislocation.
A review of Medicare records between 1983 and 1985 indicated a perioperative (30-day) mortality rate of 0.95% for all patients over the age of 65 undergoing hip surgery for reasons other than hip fracture (25). The rate increased by age group, with a mortality rate of 3.75% in those patients over the age of 85. One patient in this study died approximately 6 weeks postoperatively as a result of a preexisting, chronic, urinary tract infection that became systemic. Phillips and colleagues (22), in 1987, reported two perioperative deaths in 100 consecutive cases of elderly patients undergoing THA, one secondary to a myocardial infarction and one as a result of a pulmonary embolus. However, more recent reports have reported no cases of deaths in the perioperative period following hip arthroplasty in elderly patients (13,14,21). In fact, Ritter and associates (26) recently reported a significantly greater 10-year life expectancy in elderly patients who have undergone THA than in the age-matched general population. Thus, it is concluded that THA is currently a safe procedure for elderly patients.
With regard to functional outcome and health-related quality of life, in a large series of patients undergoing THA or total knee arthroplasty, Jones and associates (27,28) concluded that joint-specific pain, function, vitality, and general health were significantly improved 6 months following joint replacement and that age was not a significant determinant of pain or functional outcome. In addition, Chang and colleagues (29) concluded that THA is cost saving or, at worst, cost effective in improving quality-adjusted life expectancy both short and long term. Our results and those of others previously cited corroborate these findings that THA results in joint-specific pain reduction or elimination and improved function.
Musculoskeletal problems are one of the most common reasons for a patient to seek medical care from his or her primary care physician. The pain and functional limitations experienced by the patient with end-stage hip osteoarthritis are easily assessed and identified. THA has been shown to be effective in patients of all ages, including those over the age of 80 years. However, THA, particularly in elderly people, is not without risk. Both medical and hip-related complications do occur, although most are minor and resolvable. Comorbidities have to be identified and treated to minimize postoperative complications and mortality. On the basis of these study results and the literature focusing on patients over the age of 80 years, we conclude that THA is, indeed, a safe and effective procedure and that primary care physicians should not hesitate to refer the active, elderly patient to an experienced arthroplasty surgeon should their patient experience severe pain and limitation of function as a result of advanced hip arthritis.
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Acknowledgments |
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Footnotes |
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Received June 18, 2002
Accepted August 9, 2002
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References |
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