Vanhustentekonivelkirurgia

EsaJämsen20.4.2017

Sidonnaisuudet• LT,dosentti,geriatrianerikoislääkäri

• erikoislääkäri,Taysin geriatrianyksikkö• kliininenopettaja,Tampereenyliopisto• akuuttigeriatrianoyl,Hatanpäänsairaala• tutkija,TekonivelsairaalaCoxa

• Tutkimusrahoitus:valtiontutkimusrahoitus,TampereenLääkäripäivienkohdeapuraha

• Luentopalkkiot:Fioca,Duodecim,Lääkäriliitto,Orion

Kliininenleikkaustulos?

Komplikaatioriski?

Kuntoutumisedellytykset?

Mitenjatkohoito/kuntoutus

toteutetaan?

Mikäonennusteenmerkitys?

Leikkauksenhyödyt

+–

aikaMukailtuK.Pitkälän/HYesityksestä.

toim

intakyky

Hyväkuntojakognitio

VarovaisuusVauhtihidastuu

LihaskatoVäsymys

OsteoporoosiToimintakyvynlaskuAvuntarpeenkasvuMökkiytyminen

DepressioKaatumisetInfektiotMurtumat Sairaalahoidot

InkontinenssiDeliriumDementia Laitoshoito

Liikuntakykyynvaikuttavasairaus

UlkoiluväheneeProteiininsaantivähenee

Sosiaalisenympäristönkaventuminen”kukaaneivälitä”

Nivelrikonmerkitys

aikaMukailtuK.Pitkälän/HYesityksestä.

toim

intakyky

Hyväkuntojakognitio

VarovaisuusVauhtihidastuu

LihaskatoVäsymys

OsteoporoosiToimintakyvynlaskuAvuntarpeenkasvuMökkiytyminen

DepressioKaatumisetInfektiotMurtumat Sairaalahoidot

InkontinenssiDeliriumDementia Laitoshoito

Liikuntakykyynvaikuttavasairaus

UlkoiluväheneeProteiininsaantivähenee

Sosiaalisenympäristönkaventuminen”kukaaneivälitä”

Nivelrikonmerkitys

Leikkaustulokset

• Elämänlaatuparanee• Kliinisetpisteytykset(KSS,HHS)paranevat

• Leikkauksellasaavutettuparannusriippumatoniästä.

• 3kk– 8v.seurannassa• Elämänlaatuparanee• Knee Scoren muutosriippumatoniästä.

• Toimintakykyparanee…

Jämsenym.SOT2006,Santaguida ym.CanJSurg 2008, Kennedyym.CORR2013,Kennedyym.Surgeon 2013.

dailymail.co.uk

Vekama ym.Aging Clin Exp Res.2015

Tulostaennustavattekijät

HyväADL-score• Ikäalle80v.• Miessukupuoli• Eitarvettaapuvälineilletaiapuvälinevainulkokäytössä

• Eisydänsairautta• (Anemia,vaikeamunuaistenvt?)

ADL-score parani• Miessukupuoli• Kellgren-Lawrence 4(vs.2-3)

• Muttaeijoint space width

• Varus-suunnanvirheasentopreop.

• Muttaeivirheasennonvaikeus

ASA-luokka,Charlson Comorbidity Score taiuseimmatyksittäisetsairaudeteivätennustaneetkumpaakaan,myöskäänBMI:llä eivaikutusta.

Komplikaatiot

• Yli80-85-vuodenikälisääkomplikaatioriskiäx2-3verrattunaalle60-65-vuotiaisiin

• Vrt.ASA3-4à riskin.x1.5

• Yli90v.ikäaltistaasydän- (x2.5)janeurologisille(x2.1)komplikaatioillejasaattaalisätäkuolleisuutta.

• Ikäeivaikutakirurgisiinkomplikaatioihin.

• >75v.ikä,AlzheimerintautijaParkinsonintautialtistavatsairaalahoidonpitkittymiselle.

Easterlin ym.CORR2013,Kennedyym.CORR2013,Belmont ym.JBJSAm2014,D’Apuzzo ym.JArthroplasty 2014,Jauregui ym.JArthroplasty 2015,Miric ym.JArthroplasty 2015.

Miteniäkkäättekonivelpotilaatpitäisihoitaa?

1. Leikkaaoikeatpotilaat.

2. Leikkaariittävänaikaisin.

3. Leikkaavainkerran.

Vanhuspotilaanarvioinninkolminaisuus

SairaudetToimintakyky

Geriatrisetoireyhtymät

Tekonivelpotilaansairaudet(75+)Sairaus EsiintyvyysVerenpainetauti 56-76%Sydän- javerisuonisairaudet 33-40%Diabetes 8-20%Aivoverenkiertohäiriö 11%Krooninenkeuhkosairaus 10-14%Syöpä/jälkitila 9-15%Munuaisten vajaatoiminta 30%Muistisairaus 2-3%Depressio 3-8%Aiempiamurtumia 18%

Jämsenym.2014,Vekama ym.2015.

Liikunta- jatoimintakykyennustavatkuolleisuuttaActa Orthopaedica 2013; 84 (1): 44–53 47

recipients) underwent another joint replacement during the observation period. 20 hip replacements (2.6%) and 24 knee replacements (1.9%) were later revised.

Postoperative mortality and overall patient survival278 patients (14%) died during their follow-up (median 4.2 (0–7.6) years). For surviving patients, median follow-up was 4.4 (2.2–7.6) years. Mortality was 0.10% (n = 2) at 7 days, 0.15% (n = 3) at 30 days, 0.35% (n = 7) at 90 days, and 1.60% (n = 32) at 1 year.

Mortality at 1, 3, and 5 years after surgery was 1.6% (CI: 1.0–2.2), 7.6% (CI: 6.4–8.8), and 16% (CI: 13.7–17.7), respectively, and there was no difference between hip and knee replacements (adjusted HR = 1.0, CI: 0.8-1.3, for hip replacements compared to knee replacements).

Mortality rates at 1, 3, and 5 years for different patient sub-groups and adjusted HRs for overall mortality are given in Table 2. The results of respective univariate analyses are given in the Appendix (see Supplementary data).

Patient characteristicsDuring the first postoperative year, mortality was higher in the age groups 80–84 years (2.3%, adjusted HR = 2.4, CI: 1.1–5.3) and * 85 years (3.2%, adjusted HR = 3.2, CI: 1.2–8.8) than in patients aged 75–79 years (0.9%) but in general, 1-year mortality was low (Figure 1). The differences between the age groups persisted as the follow-up progressed. Men had higher mortality than women (Table 2).

Lowest 1-year mortality was observed in overweight patients and lowest overall mortality was observed in obese patients, and altogether high BMI showed a protective effect

against mortality, even after adjustment (Table 2). This effect was particularly apparent in hip replacements (adjusted HR per increase of 1 kg/m2 = 0.91, CI: 0.86–0.96) whereas fol-lowing knee replacement BMI had no effect on mortality (adjusted HR per increase of 1 kg/m2 = 0.99, CI: 0.96–1.03).

ASA risk score was strongly associated with overall mor-tality (Table 2), whereas there was no statistically signifi-cant effect on 1-year mortality (data not shown). Preopera-tive anemia (see below) and severe renal insufficiency were associated with higher mortality, independent of ASA score (Table 2).

Preoperative clinical statePreoperative functional limitations (Figure 2) and poorer pre-operative clinical state, approximated with HHS and KSS, and “severe OA” were associated with higher mortality (Table 2). The association between walking distance and mortality was essentially similar for hip and knee replacements (data not shown) and in the 3 age groups (Figure 3). After adjustment, a statistically significant association with mortality was only observed for the category “inability to walk/indoors only” (combined due to small case numbers) compared to “over 1 km” in the age groups 80–84 years and * 85 years (adjusted HR = 2.1, CI: 1.1–3.8, and adjusted HR = 2.5, CI: 1.1–6.0, respectively).

Surgery-related factorsExcept for blood transfusions, none of the operation-related variables tested had any effect on mortality in the adjusted analyses (Table 2).

Figure 2. Kaplan-Meier survival curves with death as endpoint fol-lowing primary hip or knee replacement, with respect to preoperative walking ability.

Figure 1. Kaplan-Meier survival curves with death as endpoint for patients aged 75–79 years, 80–84 years, and * 85 years at the time of primary hip or knee replacement.

Act

a O

rthop

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

85.7

6.17

3.77

on

01/2

3/14

For p

erso

nal u

se o

nly.

Jämsenym.ActaOrthop 2013.

Toimintakykyynvaikuttavattekijät

• Muuttuki- jaliikuntaelinsairaudet• Nivelenliikelaajuudet,kipu• Lihasheikkous

• Lihavuus,diabetes• Kognitionheikentyminen• Vajaaravitsemus• Hauraus-raihnaus-oireyhtymäeligerastenia (frailty)

• Ympäristötekijät

• Muistisairaus• Hidastaatoipumista• Voialtistaamurtumille• Heikentääennustetta

• Vajaaravitsemus• Pidentääsairaalahoidonkestoa• Altistaakomplikaatioille,varsinkininfektioille

• Frailty• Pitkittäätoipumistajaaltistaareadmissioille

• Lisääkuolleisuutta

Kauppilaym.Risabil Rehab 2009.vanDijk ym.Arch Phys Med Rehab 2010.Reeuwijk ym.Clin Rheum 2010.Steinhilber ym.JGeriatr Phys Ther 2014.

Huangym.JArthroplasty 2013.Lavernia ym.CORR2014.Jämsenym.BJJ2015,McIsaac ym.BJJ2016,McIsaac ym.JAMASurg 2016

Tekonivelleikkauksenajoittaminen

• Lähetetulisitehdäennenkuintoimintakyvynalenemaonpitkittynytjakipuonvaikeaa.(NICE2014)

• Vaikeanivelrikkoà• Toipuminenkestääpidempään.• Kuolleisuussuurempi.• Komplikaatiot?• Leikkaustulosjääheikommaksi(vaikkahyötysuurempi).

Kennedyym.Surgeon 2013

Uusintaleikkauksetvanhuksilla

• 170lonkkarevisiotayli80-vuotiaillapotilailla• Vertailuryhmänä<70-vuotiaat

• EieroaHHS:ssa• Lähes60%kuolleisuuskeskim.5,3v.seurannassa

• 10%:lleuusintatoimenpiteitä

Parvizi ym. JBJS Am 2007.

Jämsenym.Clin Orthop Relat Res 2014.

Tekonivelvalinnanmerkitys

Take homemessage:Kannattaaleikata,kunhan…

1. Leikkaaoikeatpotilaat.

2. Leikkaariittävänaikaisin.

3. Leikkaavainkerran.

Tobe continued

Lähde: Endoproteesirekisteri. (julkaisematon havainto)

Alle6565-7475-8485-9495taiyli

Preoperatiivinen /leikkauskelpoisuudenarviointi

Selvitetäänterveydentila.

Arvioidaanriskitekijät.

Leikkauskelpoinen Eileikkauskelpoinen

Suunniteltuhoito Reagoidaankomplikaatioihin

Järjestetääntarvittavajatkohoito

Sydän,keuhkot,anemia,diabeteksenhoitotasapaino

Preoperatiivinen arviointijaoptimointi

Selvitetäänterveydentilaml.diagnosoimattomatsairaudetjaoireyhtymät

Puututaanmodifioitavissaoleviin

ongelmiin

Suunniteltuhoito Komplikaatioidenennaltaehkäisy

Suunniteltujatkohoitojakuntoutus

Kokonaisvaltaiseenarvioonperustuvahoitosuunnitelma

(shared decision making)

POPSurologiassajaortopediassa(ennen/jälkeen-asetelma)

Urologia(n=112+130)• Hoitoaikalyhyempi4,0vs.4,9päivää,p=0,014

• Vähemmänkomplikaatioita(sekämedisiinisetettäkirurgiset),OR0,24(0,10-0,54)

• Trendit• vähemmänperuttujaleikkauksiasuuntaan:5vs.10%,p=0,12.

• Vähemmä readmissioneita:3vs.8%,p=0,07

Ortopedia(n=54+54)• Hoitoaikalyhyempi11vs.15päivää,p=0,028

• Vähemmändeliriumia6vs.18%,p=0,036

• Vähemmätinfektioita• Haavainfektio2vs.12%,p=0,004• Pneumonia2vs.11%,p=0,008

• Nopeampitoimintakyvynpalautuminen

Harari ym.Age Ageing 2007,Braude ym.BJUInt 2016.

TekonivelleikkauksetParkinson-potilailla(Jämsenym.BJJ2014)

• 857Parkinson-potilasta+kaltaistetutverrokit

• pidempihoitoaika(21vs.13päivää)• lonkkaluksaatioriskix2,3• pitkäaikaisseurannassasuurempimortaliteetti

• vain35%elossa10v.kohdalla

TekonivelleikkauksetAlzheimer-potilailla(Jämsenym.BJJ2015)

• 1064Alzheimer-potilasta+kaltaistetutverrokit

• pidempihoitoaika(13vs.8päivää)• suurempilonkkarevisioriskix1,8

• erityisestirevisiotdislokaationtakiavaikkadislokaatioriskissä eieroa

• pitkäaikaisseurannassasuurempimortaliteetti

• vain1/3elossa10v.kohdalla

Landi F ym. J Clin Epid 2010.

Ikäjasairaudeteivätkerrokaikkea…

Itsenäinenselviytyminen

Toim

intakyky

Itsenäinen

Avuntarvekodinulkopuolellaasioinnissa/raskaissakotitöissä

Avuntarvehenkilökohtaisissapäivittäistoiminnoissa.

Runsas/yhtämittainenavuntarve

Muttaikäjasairaudeteivätkerrokaikkea…

Itsenäinenselviytyminen

Hoidakuinketätahansaaikuista.

Maltillisemmathoitotavoitteet.Hoidonhaittojenminimointi.Sekundääripreventio.

Maltillisethoitotavoitteet.Eitavoitellaennustevaikutusta.Hoidonhaittojenminimointi.Oireidenhoitojatoimintakyvynylläpito.

Itsenäinen

Avuntarvekodinulkopuolellaasioinnissa/raskaissakotitöissä

Avuntarvehenkilökohtaisissapäivittäistoiminnoissa.

Runsas/yhtämittainenavuntarve

HRO=hauraus-raihnaus-oireyhtymä=gerastenia =frailty

Kuvat:Clinical Frailty Scale

• ‘‘abiologic syndrome ofdecreased reserveandresistance tostressors,resulting fromcumulative declines across multiplephysiologic systems andcausingvulnerability toadverse outcomes’’(Fried ym.2001)

• Seuraukset• heikentynytviiveiden/ongelmiensietokyky• hidastunuttoipuminen• komplikaatioalttius• suurempijatkohoidonja-kuntoutuksentarve• suurempikuolleisuus

https://www.flickr.com/photos/vehvilainen/5051838549

HRO=hauraus-raihnaus-oireyhtymä=gerastenia =frailty

• 300potilastapolvitekonivelpotilastaCoxasta,167:ltäriittävättiedot

• Ensitekonivelleikkausnivelrikkondikaatiolla• 75-89-vuotiaita63%naisia• Kyselypreop javuosipostop.

• Toimintakykykymmenessäpäivittäistoiminnossa

• (WOMAC)• Pitkäaikaissairaudetsairauskertomustiedoista.

Anesth Analg. 2016 Jun;122(6):1807-15. doi: 10.1213/ANE.0000000000001190.Postoperative Morbidity and Discharge Destinations After Fast-Track Hip and Knee Arthroplasty in Patients Older Than 85 Years.Pitter FT1, Jørgensen CC, Lindberg-Larsen M, Kehlet H; Lundbeck Foundation Center for Fast-track Hip and Knee Replacement Collaborative Group.Author informationAbstractBACKGROUND:Elderly patients are at risk of increased length of hospital stay (LOS), postoperative complications, readmission, and discharge to destinations otherthan home after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). Recent studies have found that enhanced recovery protocolsor fast-track surgery can be safe for elderly patients undergoing these procedures and may result in reduced LOS. However, detailed studies on preoperative comorbidity and differentiation between medical and surgical postoperative morbidity in elderly patients are scarce. The aim of thisstudy was to provide detailed information on postoperative morbidity resulting in LOS >4 days or readmissions <90 days after fast-track THA and TKA in patients ≥85 years.METHODS:This is a descriptive, observational study in consecutive unselected patients ≥85 years undergoing fast-track THA/TKA. The primary outcome wasthe causes of postoperative morbidity leading to an LOS of >4 days. Secondary outcomes were 90-day surgically related readmissions, dischargedestination, 90-day mortality, and role of disposing factors for LOS >4 days and 90-day readmissions. Data on preoperative characteristics wereprospectively gathered using patient-reported questionnaires. Data on all admissions were collected using the Danish National Health Registry, ensuring complete follow-up. Any cases of LOS >4 days or readmissions were investigated through review of discharge forms or medical records. Backward stepwise logistic regression was used for analysis of association between disposing factors and LOS >4 days and 90-day readmission.RESULTS:Of 13,775 procedures, 549 were performed in 522 patients ≥85 years. Median age was 87 years (interquartile range, 85-88) and median LOS of 3 days (interquartile range, 2-5). In 27.3% procedures, LOS was >4 days, with 82.7% due to medical causes, most often related to anemia requiringblood transfusion and mobilization issues. Use of walking aids was associated with LOS >4 days (odds ratio [OR], 1.99; 95% confidence interval[CI], 1.26-3.15; P = 0.003), whereas preoperative anemia showed borderline significance (OR, 1.52; 95% CI, 0.99-2.32; P = 0.057). Thirty-eightpatients (6.9%) were not discharged directly home, of which 68.4% had LOS >4 days. Readmission rates were 14.2% and 17.9% within 30 and 90 days, respectively, and 75.5% of readmissions within 90 days were medical, mainly due to falls and suspected but disproved venousthromboembolic events. Preoperative anemia was associated with increased (OR, 1.81; 95% CI, 1.13-2.91; P = 0.014) and living alone withdecreased (OR, 0.50; 95% CI, 0.31-0.80; P = 0.004) risk of 90-day readmissions. Ninety-day mortality was 2.0%, with 1.0% occurring duringprimary admission.CONCLUSIONS:Fast-track THA and TKA with an LOS of median 3 days and discharge to home are feasible in most patients ≥85 years. However, further attention to pre- and postoperative anemia and the pathogenesis of medical complications is needed to improve postoperative outcomes and reducereadmissions.

JAMA Surg. 2016 Jun 1;151(6):538-45. doi: 10.1001/jamasurg.2015.5085.Association of Frailty and 1-Year Postoperative Mortality Following Major ElectiveNoncardiac Surgery: A Population-Based Cohort Study.McIsaac DI1, Bryson GL2, van Walraven C2.Author informationAbstractIMPORTANCE:Single-center studies identify frailty as a risk factor for 30-day postoperative mortality. Thelong-term and population-level effect of frailty on postoperative mortality is, to ourknowledge, poorly described, as are the interactions of frailty with important predictors of mortality.OBJECTIVE:To measure the population-level effect of patient frailty on, and its association with, 1-year postoperative mortality.DESIGN, SETTING, AND PARTICIPANTS:Population-based retrospective cohort study in Ontario, Canada, with data collectedbetween April 1, 2002 and March 31, 2012. Analysis was performed from December 2014 to March 2015. All patients were community-dwelling individuals aged 65 years or older on the day of elective, major noncardiac surgery.EXPOSURE:Frailty, as defined by the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-definingdiagnoses indicator. The ACG frailty-defining diagnoses indicator is a binary variable thatuses 12 clusters of frailty-defining diagnoses.MAIN OUTCOMES AND MEASURES:One-year all-cause postoperative mortality.RESULTS:Of 202 811 patients, 6289 (3.1%) were frail (mean [SD] age, 77 [7] years). Within 1 year, 13.6% (n = 855) of frail and 4.8% (n = 9433) of nonfrail patients died. Adjustment for sociodemographic and surgical confounders resulted in a hazard ratio of 2.23 (95% CI, 2.08-2.40). The interaction between frailty and postoperative time demonstrated an increased relative hazard for death in frail patients (hazard ratio, 35.58; 95% CI, 29.78-40.19) on postoperative day 3. The association between frailty and increased risk of deathdecreased with patient age (HR, 2.66; 95% CI, 2.28-3.10 at age 65; HR, 1.63; 95% CI, 1.36-1.95 at age 90). Significant variations in the increased risk for death in frail patientsexisted between different surgery types and was strongest after total joint arthroplasty (HR, 3.79; 95% CI, 3.21-4.47 for hip replacement; HR, 2.68; 95% CI, 2.10-3.42 for kneereplacement).CONCLUSIONS AND RELEVANCE:At a population level, preoperative frailty-defining diagnoses were associated with a significantly increased risk of 1-year mortality that was particularly notable in the earlypostoperative period, in younger patients, and after joint arthroplasty.

Bone Joint J. 2016 Jun;98-B(6):799-805. doi: 10.1302/0301-620X.98B6.37124.The impact of frailty on outcomes and healthcare resource usage after total jointarthroplasty: a population-based cohort study.McIsaac DI1, Beaulé PE2, Bryson GL1, Van Walraven C3.Author informationAbstractAIMS:Total joint arthroplasty (TJA) is commonly performed in elderly patients. Frailty, an aggregateexpression of vulnerability, becomes increasingly common with advanced age, and independently predicts adverse outcomes and the use of resources after a variety of non-cardiac surgical procedures. Our aim was to assess the impact of frailty on outcomes after TJA.PATIENTS AND METHODS:We analysed the impact of pre-operative frailty on death and the use of resources after electiveTJA in a population-based cohort study using linked administrative data from Ontario, Canada.RESULTS:Of 125 163 patients aged > 65 years having elective TJA, 3023 (2.4%) were frail according to the Johns Hopkins ACG frailty-defining diagnoses indicator. One year follow-up was completefor all patients. Frail patients had a higher adjusted one year risk of mortality (hazard ratio 3.03, 95% confidence interval (CI) 2.62 to 3.51), a higher rate of admission to intensive care (oddsratio (OR) 2.52, 95% CI 2.21 to 2.89), increased length of stay (incidence rate ratio 1.62, 95% CI 1.59 to 1.65), a higher rate of discharge to institutional care (OR 2.09, 95% CI 1.93 to 2.25), a higher rate of re-admission (OR 1.33, 95% CI 1.07 to 1.66) and increased costs at 30, 90 and 365 days post-operatively. Frailty affected outcomes after total hip arthroplasty more than aftertotal knee arthroplasty.TAKE HOME MESSAGE:Frailty is an important risk factor for death after elective TJA, and increases post-operativeresource utilisation across many metrics. Processes to optimise the outcomes and efficiency of TJA in frail patients are needed.

Ann R Coll Surg Engl. 2016 Apr;98(4):258-64. doi: 10.1308/rcsann.2016.0095. Epub 2016 Feb 29.Clinical outcome following primary total hip or knee replacement in nonagenarians.Skinner D1, Tadros BJ1, Bray E1, Elsherbiny M1, Stafford G1.Author informationAbstractIntroduction The Elective Orthopaedic Centre in Epsom has an established patient reportedoutcome measures programme, into which all patients are enrolled. Postoperative complications, Oxford hip/knee scores (OHS/OKS) and EQ-5D™ (EuroQol, Rotterdam, Netherlands) scores arecollected up to the second postoperative year. Our population is ageing and the number of jointreplacements being performed on the very elderly is rising. The aim of this study was to investigatethe outcome of joint replacements in a nonagenarian population. Methods Our dataset wasreviewed retrospectively for a cohort of nonagenarians undergoing either a primary total hip replacement (THR) or total knee replacement (TKR) between April 2008 and October 2011. Postoperative complications, mortality rates and functional outcomes were compared with those of a time matched 70-79-year-old cohort. Results Nonagenarians requiring a THR presented with a lower preoperative OHS (p=0.020) but made a greater improvement in the first postoperative yearthan the younger cohort (p=0.040). The preoperative OKS was lower for nonagenarians than for thecontrol group (p=0.022). At one and two years after TKR, however, there was no significantdifference between the age groups. The nonagenarians had a greater risk of requiring a bloodtransfusion following both THR (p=0.027; 95% confidence interval [CI]: 1.11-5.75) and TKR (p=0.037; 95% CI: 1.08-16.65) while the latter cohort also required a longer stay than their youngercounterparts (p=0.001). Mortality rates were higher in the nonagenarian group but these were in keeping with the life expectancy projections identified by the Office for National Statistics. Conclusions Over a two-year period, the functional outcome and satisfaction rates achieved bynonagenarians following a THR or TKR are comparable with 70-79-year-olds.