Patient Populations That Should be Strongly Discouraged From Having Surgery
Assessment of comorbidity is important to provide the patient and family with the information necessary to make educated decisions regarding the risk:benefit ratio of proceeding with surgery. After the medical risks have been identified and quantified, it should be possible for the patient to compare the benefit of hip replacement with the risk of having a hip replacement. Most of the previously discussed medical comorbidities are not absolute contraindications, and should be carefully balanced with the patients' pain and disability. By contrast, there are certain conditions in the very elderly that most consider an absolute contraindication to hip replacement surgery, as other pain relieving surgeries are sometimes equally as effective while carrying a lower perioperative and postoperative risk.
Dementia of varying severity is quite commonly observed in the very elderly population presenting for hip replacement, with higher rates in patients who are homebound. Furthermore, family and carer involvement is available in varying degrees for these patients. Although the quantification and evaluation of dementia severity is not a standard practice of hip replacement surgeons, a general understanding of the patient's dementia is attained through conversation with the patient, their family and primary physician.
The main surgical consideration when evaluating patients with dementia is whether they will be able to cooperate with perioperative directions and treatments. The postoperative period requires that the patient will voluntarily accept medications, food, hydration, wound care and physical therapy sessions. Furthermore, the patient must remember not to ambulate alone in the early postoperative period, utilize a walker or cane, and exercise certain precautions. The patient or surgeon cannot expect to have a good surgical outcome if these basic directions and necessities cannot be followed.
The patient's ability to participate in perioperative care is critical; a function of both the severity of their dementia and their surrounding support and care system. If it is clear that the patient will be unable to properly cooperate with postoperative care needs, and that their carers will not be able to compensate for the patient's inability, then most surgeons would not consider proceeding with surgical intervention. Ritter and Harty described their experience performing 14 THAs in patients with dementia syndromes. Half of their patients experienced postoperative disorientation, and were likely to interfere with care by removing their own catheters and intravenous lines, displaying aggressive behavior, getting out of bed unattended and falling out of bed. Clearly, the very elderly patient with dementia is at an elevated risk of complications after surgery. However, when their dementia is severely advanced and their carers are unable to participate in care, moving forward with THA is highly discouraged.
Severe Functional Disability
Occasionally, a very elderly patient has multiple physical disabilities due to varying etiologies. The incidence of heart failure, anemia, depression, malnourishment, spinal stenosis, radiculopathy and claudication is higher in the very elderly and can impede function quite significantly. When severe, these conditions can limit a patient's ability to ambulate. If a very elderly patient becomes bed bound from etiologies other than an arthritic hip, the incremental benefit of hip replacement diminishes. In these situations, persistent intolerable pain may be more appropriately managed by a resection arthroplasty, which involves removal of the femoral head without prosthetic implantation. Resection arthroplasty can treat the hip pain while simultaneously avoiding or minimizing many of the risks of joint replacement, such as infection, dislocation and periprosthetic fracture.
Aging Health. 2011;7(6):803-811. © 2011 Future Medicine Ltd.