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

Hip Fracture Population Pre-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

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: 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 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 Arthroplasty in 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%

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