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Outcomes of Complex Reconstruction in the Elderly

Review surgical outcomes of hip fracture in the elderly, discuss pre-injury health impact, and propose tailored treatments for "fit" vs. "frail" patients. Guidelines for optimized surgical care are provided based on recent studies and comparative outcomes.

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Outcomes of Complex Reconstruction in the Elderly

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  1. Outcomes of Complex Reconstruction in the Elderly Curriculum in Geriatrics for Orthopedic Specialists

  2. 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.

  3. 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

  4. 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

  5. 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

  6. Hip Fracture PopulationPre-injury Health Status • Recent studies clearly demonstrate importance of pre-injury health status on outcome • Fit vs Non-fit • For example: Nutritional Status as a surrogate for fitness JBJS 74A 1992; 74A: 251-260

  7. 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

  8. 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

  9. 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”

  10. Outcomes after Femoral Neck Fracture Blomfeldt, R et al: JBJS 2005; 87A: 1680-1688

  11. Outcomes after Femoral Neck Fracture Blomfeldt, R. et al: JBJS 2005; 87A: 1680-1688

  12. 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

  13. 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 Displaced Femoral Neck Fractures:The Evidenced-Based Algorithm

  14. 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. • 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%

  15. 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

  16. Total Joint ReplacementThe Octogenarian Birdsall et al: JBJS 81B: 1999

  17. Total Joint ReplacementThe Octogenarian Berend et al: J Arthroplasty 18: 2003

  18. 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

  19. 94 y.o. Female unable to walk for 6 months due to hip pain

  20. 94 y.o. female: post-op radiographs after staged THR’s

  21. 88 y.o. Retired Chemist: worked for Johnson and Johnson

  22. 3 Months after Revision THR

  23. 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

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