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

Evaluating the Risks of Hip Replacement

Once the decision has been made that surgery is indicated, it is especially important to evaluate the surgical risks associated with operating on the very elderly.[18] Assessing this risk and comparing it to potential benefits allows the patient and their family to make an informed and intelligent decision. Evaluation of risk is generally conducted in consultation with the patient's primary care physician, as they have the best perspective and knowledge of the patient's condition.

Cardiovascular Risk

Cardiovascular disease can result in serious medical complications after total joint replacement. Myocardial infarction, congestive heart failure and arrhythmia are only a few of the conditions which can be triggered by the stress of surgery, leading to significant medical care needs after surgery.[19–21] The very elderly patient should be thoroughly screened before surgery for arterial, valvular and electrophysiological disease. Often, surgical or medical interventions can reduce the risks of hip replacement by addressing these diseases preoperatively. In situations where reversal of cardiovascular disease is either impossible or associated with excessive risk, then the patient and their family can be counseled regarding the additional perioperative risks that they must accept if continuing with hip replacement.

Pulmonary Risks

The perioperative period can introduce several stressors to the pulmonary system. Perioperative sedation, pain management and immobility can produce aspiration events, atelectasis and apnea. Patients with a known history of diseases such as chronic obstructive pulmonary disease, pulmonary fibrosis and sleep apnea should have these conditions evaluated and addressed before surgery. The goal is to optimize their physiology and generate an appropriate perioperative anesthetic and pain management plan to minimize the overall pulmonary risk. Appreciation of irreversible and significant pulmonary conditions will certainly cause great hesitancy in proceeding with a hip replacement.

Renal Risks

Renal insufficiency, renal failure and the need for dialysis can introduce significant perioperative risks for the very elderly patient having a hip replacement.[22] Many of the postoperative pain medications, including aspirin, cyclooxygenase inhibitors and nonsteroidal anti-inflammatory compounds should be used with care in this population, as worsening perioperative renal function can be a cause for concern. Patients with end-stage renal failure, and especially those on dialysis, are at an increased risk of infection after joint replacement. In fact, many surgeons consider end-stage renal failure an absolute contraindication for joint replacement in very elderly patients given the significant risk of deep infection.[23–25]

Comorbid Infection

The very elderly population is at risk for infection and patients often present with chronic or acute infections of the urinary system, oral cavity, pulmonary system and dermatologic system. Although perioperative prophylactic antibiotics are administered before joint replacement, identification and treatment of these chronic or acute infections is recommended given the risk of bacteremia and seeding of the surgical site.

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