Transcript Outcomes of Complex Reconstruction in the Elderly

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 Practice
Outcomes 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 Elderly
Hip 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 Hip
Mortality 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 preinjury health status
Artist: C Cornell, M.D. NYC, N.Y
Hip Fracture Population
Pre-injury Health Status
• Recent studies
clearly demonstrate
importance of preinjury health status
on outcome
• Fit vs Non-fit
• For example:
Nutritional Status as
a surrogate for
fitness
JBJS 74A 1992; 74A: 251-260
Fractures of the Hip
Predictors 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 Fractures
The “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:
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•
•
Persistent pain
High Re-op Rate
Functional disability
Therefore: Proper Tactic
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•
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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
2 7.3mm screws
WBAT post-op
ORIF
Fit Pt
Frail Pt
THR
Cemented
Hemi
Total Joint Arthroplasty
in Patients of advanced Age
•
•
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In 2000: 1.5% of the pop were older than 85
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:
1995
- 136 THR’s per 10,000
- 33,851 performed
- Mortality rate 2.3%
Total Joint Arthroplasty
The 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 Replacement
The Octogenarian
Birdsall et al: JBJS 81B: 1999
Total Joint Replacement
The 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
6 months due to hip pain
94 y.o. female: post-op
radiographs after staged THR’s
88 y.o. Retired Chemist: worked
for Johnson and Johnson
3 Months after Revision THR
Reconstruction in the Elderly
Summary
• 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