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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

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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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