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

The Ideal Candidate

The ideal result after THA is a durable implant that provides the patient with a painless, fully functional hip. Obtaining this result is significantly influenced by patient factors that can be determined preoperatively. Patient satisfaction is a subjective measure that is highly dependent on the patient's preoperative state. For example, patients with advanced arthritis and severe pain notice the largest subjective improvement after THA and are often the most satisfied patients, even if their ultimate function is not ideal. Conversely, patients with an objectively excellent result are sometimes found to be less satisfied due to the fact that their subjective outcome is not such a dramatic change compared with the preoperative condition.[9]

Similarly, the ultimate functionality after THA is generally related to preoperative strength and function. For example, a patient who has been wheelchair bound cannot expect to have the same functional outcome as a recent triathlete who had severe pain but no limp before surgery. Muscle strength and flexibility are required to ambulate with a normal gait pattern. Comorbid conditions such as spinal stenosis or arthritis of the spine, knee or ankle can diminish the ultimate functional result after THA.

Implant longevity has always been a primary concern for surgeons, especially when performing a THA on a younger patient. Although implant-related characteristics are certainly factors that influence their longevity, it is also quite clear that patient-related characteristics are contributory. Certainly as the age of the patient advances there is a lower likelihood that the implants will mechanically fail through their lifetime. Furthermore, elevated activity levels and mechanical stresses on the implants can lead to a shortened implant lifespan, as evidenced by a shorter time to revision after THA in very young patients.[15,16] In general, when considering implant longevity, advancing age is considered a desirable patient characteristic.[17] However, this preference for older patients is tempered by the increasing rate of medical comorbidities in the elderly. As preoperative medical comorbidities increase, so does the likelihood that a perioperative complication will occur. Therefore, defining the ideal candidate for hip replacement should specify that the older patient has few comorbidities.

A description of the ideal candidate for THA is, therefore, predicated on several considerations that would be associated with an ideal outcome as described above. A healthy elderly patient who is a community ambulator requiring either a cane or no assist device provides an optimal combination of characteristics. They would likely have an excellent functional result with minimal risk of implant failure through their expected lifetime. If this patient also had advanced arthritis and significant pain before surgery, the level of patient satisfaction after surgery would also be optimized.

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