Outcomes of Complex Reconstruction in the Elderly

Curriculum in Geriatrics for Orthopedic Specialists

Impact on Utilization of Healthcare Resources

Aging of the US society will have a Clear Impact on Practice:

• By 2040: 20% or 77.2 million will be older than 65

• Currently the need for TJR in the elderly is 15/10,000

- 2000: 500K TKR’s

- 2040: 3.48M TKR’s/yr

Artist: C Cornell, M.D. NYC, N.Y.

Current Orthopedic PracticeOutcomes in the Elderly

• Increasing demand for treatment of age related fractures and degenerative joint disease in patients older than 80 years

• Considerable experience now reported• Purpose:

-To review the results of surgical Rx in this population- To suggest general principles in approaching the elderly patient that needs reconstructive surgery

Surgical Outcomes in the ElderlyHip Fracture Paradigm

Traditional Wisdom:• Survival and functional

recovery are poor• Preservation of the

femoral head vs arthroplasty is desirable

• Most studies have assumed that the hip fx population is homogeneous

Fractures of the HipMortality after Treatment

• Increased 1 yr mortality (12-25%) compared to age matched population

• Returns to baseline after 1 yr.

• 5 yr survival is 50%• Survival is best

predicted by pre-injury health status Artist: C Cornell, M.D. NYC, N.Y

Hip Fracture PopulationPre-injury Health Status

• Recent studies Recent studies clearly demonstrate clearly demonstrate importance of pre-importance of pre-injury health status injury health status on outcomeon outcome

• Fit vs Non-fit Fit vs Non-fit • For example: For example:

Nutritional Status as Nutritional Status as a surrogate for a surrogate for fitnessfitness

JBJS 74A 1992; 74A: 251-260

Fractures of the HipPredictors of Morbidity and Mortality

• Pre-injury health is the best predictor of outcome

• Within any hip fx pop. are 2 subgroups

- “Fit Elderly”

- “ Frail Elderly”Artist: C Cornell, M.D. NYC, N.Y

Displaced Femoral Neck FracturesThe “Fit” Elderly Patient

• Definition of “Fit” not a function of age

• Few comobidities (<3)• Independent

community ambulation• Manage their social

affairs• Actively engaged in

sports or social activity

Hip Fracture Populations

• Not Homogeneous!!• Fit vs. Frail• Treatment must be tailored by patient

characteristics and not diagnosis• Evidenced by comparative outcomes of

ORIF vs Hemiarthroplasty vs THA• Studies by Blomfeldt et al and Healey

clearly demonstrate superiority of THA in “Fit Elderly”

Outcomes after Femoral Neck Fracture

Blomfeldt, R et al: JBJS 2005; 87A: 1680-1688

Outcomes after Femoral Neck Fracture

Blomfeldt, R. et al: JBJS 2005; 87A: 1680-1688

Lessons Learned From Femoral Neck Fractures:

Guidelines for Surgical Care of the Elderly

Pinning is a poor choice for Femoral Neck Fx because:

• Persistent pain• High Re-op Rate• Functional disability

Therefore: Proper Tactic• Procedures with low need for re-op• Pain relief is key• Procedures which permit optimal

functional recovery• THR is the best overall procedure

for the “Fit” elderly patient

Displaced Femoral Neck Fractures:The Evidenced-Based Algorithm

Femoral Neck Fracture

non-displaced Displaced

< 55 yrs > 55 yrs

pinning in-situ ORIF Fit Pt Frail Pt

2 7.3mm screws THR

WBAT post-op Cemented

Hemi

Total Joint Arthroplastyin Patients of advanced Age

• In 2000: 1.5% of the pop were older than 85• In 1995: 1.25 million nonagenarians in the USA.In 1995: 1.25 million nonagenarians in the USA.• Currently the need for TJR in the elderly is

15/10,000- 2000: 500K TJR’s- 2040: 3.48M TKR’s/yr

• Incidence of THR in the nonagenarian population: Incidence of THR in the nonagenarian population: 19951995- 136 THR’s per 10,000- 136 THR’s per 10,000- 33,851 performed - 33,851 performed - Mortality rate 2.3%- Mortality rate 2.3%

Total Joint ArthroplastyThe Octogenarian

Reported Outcomes:• Berend et al ( J Arthroplasty 18;2003)• L’Insalata et al ( J Arthroplasty 7;1992)• Shah et al ( CORR 425:2004 ) Improvement in hip and knee scores is comparable

to younger series Revisions only for infection: TKR higher infection

risk than THR Higher risk of perioperative complications*: longer

hospital stays but low perioperative mortality

* Delerium, MI, Pneumonia, UTI and Decubitius Ulcer

Total Joint ReplacementThe Octogenarian

Birdsall et al: JBJS 81B: 1999

Total Joint ReplacementThe Octogenarian

Berend et al: J Arthroplasty 18: 2003

Total Joint Arthroplasty in The Aged Patient

Special Considerations• Aseptic failure rare• Use constrained

components- non-modular TKR- constrained THR liners

• Bilateral Cases- 83% complications- 16% for unilaterals

• Avoid bilat’s in elderly

94 y.o. Female unable to walk for 94 y.o. Female unable to walk for 6 months due to hip pain6 months due to hip pain

94 y.o. female: post-op 94 y.o. female: post-op radiographs after staged THR’sradiographs after staged THR’s

88 y.o. Retired Chemist: worked 88 y.o. Retired Chemist: worked for Johnson and Johnsonfor Johnson and Johnson

3 Months after Revision THR 3 Months after Revision THR

Reconstruction in the ElderlySummary

• Relief of pain and restoration of mobility is achieved with TJR

• Increased but acceptable risk of complications

• “Fit vs Frail” in patient selection• Health quality and survival enhanced• Prosthetic loosening is minimal ( 0%);

consider benefit of constrained components • Avoid doing bilaterals in a single stage