Hip Replacement in the Very Elderly

Selecting a Suitable Candidate

Carl Deirmengian; Matt Austin; Greg Deirmengian

Disclosures

Aging Health. 2011;7(6):803-811. 

In This Article

Abstract and Introduction

Abstract

The selection of a suitable candidate for hip arthroplasty involves several important patient-specific considerations. Advanced age may be considered a relative contraindication for elective surgery, and may unfortunately cause a stereotypical dismissal of very elderly patients with a painful hip. However, several studies have demonstrated the exceptional safety and symptomatic benefits of hip arthroplasty in octogenarians and nonagenarians when appropriate medical precautions and preparations are utilized. The very elderly present specific social and medical scenarios that must be identified to establish an accurate risk assessment and achieve an optimal postoperative result. Although a greater likelihood of perioperative complications exists, the very elderly can expect to achieve highly significant pain relief and functional improvement after hip replacement. Future studies will focus on improvements in outcomes after hip replacement that may be realized with new advances in postoperative protocols.

Introduction

Arthritis describes a group of inflammatory diseases that hinder the normal physiology and function of a joint. This group of joint diseases is generally not life threatening, but they do have a quite negative impact on quality of life, often impeding the ability to ambulate. Debilitating joint pain, decreased joint motion and declining physical function are hallmarks of hip arthritis.[1–4] These symptoms lead to a progressive decline in exercise and ambulatory capacity, and eventual isolation from important social functions that require mobility. Although some etiologies result in hip arthritis in the young population, hip arthritis is generally considered a disease of the aging.

Total hip arthroplasty (THA) is one of the most successful surgical interventions that leads to improvement in quality of life[5–8] and provides significant improvements in both pain and function. Hundreds of studies in the literature have reported on the improvement of pain and function scores, utilizing tools such as the Hip Society Score, the Hospital for Special Surgery Hip Scale, and the D'Aubigné and Postel Score. Although the almost universally successful results after THA have been repeatedly demonstrated, there are certainly patient factors that can alter the degree of improvement. Both preoperative patient function and preoperative patient expectations have been shown to significantly influence postoperative satisfaction with THA. Mancuso et al. specifically studied patient satisfaction after THA in a cohort of 180 patients.[9] Although almost 90% of patients were satisfied with their result, there was an observed decrease in satisfaction among patients with the most severe preoperative condition and among patients who expected to perform nonessential activities. Certainly patient selection and patient education are important factors in optimizing the results of THA.

The Medicare Provider Analysis and Review (MedPAR) Part A database has provided valuable information and trends regarding the characteristics and outcomes of patients undergoing THA. In a study of 1,453,493 patients having an elective THA between 1991 and 2008, Cram et al. demonstrated that the average patient age has increased from 74.1 to 75.1 years, the prevalence of diabetes increased from 7.1 to 15.5%, and the prevalence of obesity increased from 2.2 to 7.6% among patients having a hip replacement.[10] The overall number of comorbid illnesses per patient was also observed to increase from 1.0 to 2.0. During the same time period, the average hospital length of stay decreased from 9.1 to 3.7 days and the 90-day mortality decreased from 1.2 to 0.8%. It is clear that despite the increasing age and complexity of patients undergoing an elective THA in the Medicare population, the overall hospital stay and mortality rate associated with THA have decreased.

One of the most significant recent advances in the care of patients having a THA is the evolution of the perioperative pain protocol (or rapid-recovery protocol).[11,12] An appreciation of the importance of pre-emptive pain and nausea medication combined with early ambulation has led to a reduction in the rate of pain and nausea after THA. In fact, many centers can now perform THA under spinal anesthetic and sedation, without the need for parenteral narcotics at any time during perioperative care. These advances have had quite an impressive effect on immediate postoperative outcomes.[13,14] The ability to perform THA on the elderly population without the need for parenteral narcotics is especially appealing.

The goal of this review is to consider THA in the very elderly population, which we define as patients over the age of 80 years. We explore factors relating to choosing appropriate surgical candidates, special technical factors to consider in performing the procedure and the results of THA in the very elderly.

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