Hip and Knee Arthroplasty Outcomes for Nonagenarian Patients

In This Article

Abstract and Introduction

Abstract

Introduction: Studies have previously reported higher complication rates in elective total joint arthroplasty (TJA) for nonagenarians compared with younger cohorts. The purpose of this study was to assess whether nonagenarians were still at increased risk of complications and hospital readmissions by answering three questions: (1) Do nonagenarians have an increased risk of medical complications after TJA compared with octogenarians and septuagenarians? (2) Do nonagenarians have an increased risk of surgical complications after TJA compared with octogenarians and septuagenarians? (3) Do nonagenarians have an increased risk of hospital readmission after TJA compared with octogenarians and septuagenarians?

Methods: A total of 174 patients undergoing primary TJA between 2010 and 2017 were included; 58 nonagenarians (older than 90 years) were matched with 58 octogenarians (age 80 to 84 years) and 58 septuagenarians (age 70 to 74). Groups were matched by sex, diagnosis, surgeon, surgical joint, and year of surgery. Within each group, 31 patients (53%) underwent total hip arthroplasty and 27 patients (47%) underwent total knee arthroplasty. Comorbidities, American Society of Anesthesiologists physical status scores, and Charlson Comorbidity Index scores were captured preoperatively. Complications and readmissions occurring within 90 days postoperatively were evaluated.

Results: Nonagenarians had the highest rate of medical complications (33%) compared with octogenarians (14%) and septuagenarians (3%) (P < 0.001). Rates of surgical complications were not statistically different among nonagenarians (12%), octogenarians (9%), and septuagenarians (10%) (P = 0.830). Rates of hospital readmission were highest in nonagenarian patients (11%), but not statistically different compared with octogenarians (5%) or septuagenarians (2%) (P = 0.118).

Conclusion: Nonagenarians were 3.1 times more likely to have a complication after TJA. The incidence of medical complications was highest in nonagenarians compared with octogenarians and septuagenarians, but rates of orthopaedic complications were similar. Nonagenarians who elect to proceed with TJA should be informed that they have an increased risk of postoperative medical complications compared with younger patients undergoing the same operation.

Level of Evidence: Level III, Therapeutic Study

Introduction

More than 50% of patients older than 80 years have osteoarthritis of the hip and knee, which can be a notable cause of morbidity in the elderly.^[1] Total joint arthroplasty (TJA) is an effective treatment for osteoarthritis and improves functional outcomes and patient satisfaction.^[2,3] The average life expectancy in 1960 was 69.7 years. Today, that number has increased to 78.6, although the effect of the coronavirus disease 2019 pandemic on that estimate has yet to be fully determined.^[4,5] As our health care improves, it is common to see patients living well into their eighties and nineties while maintaining an active lifestyle with an excellent quality of life. The US Census Bureau projected that in 2020, there would be 56.1 million Americans older than 65 years.^[6] These individuals are becoming potential candidates for TJA because of their improved health status and potential longevity.

Previous studies on nonagenarians undergoing TJA have demonstrated that age can be an independent risk factor for postoperative morbidity and mortality, as well as increased hospital costs.^[7–11] Nonagenarians have longer lengths of stay (LOS) and medical complications as high as 40%.^[1,9,10,12] Perioperative mortality in nonagenarians has been reported to be between 2.1% and 6.4%, potentially linked to frail health as evidenced by the increasing number of patients with multiple medical comorbidities and elevated American Society of Anesthesiologists (ASA) scores.^[1,9,10,12] Tools, such as the 5-factor modified frailty index, are available to allow surgeons to more accurately predict mortality and morbidity in patients undergoing revision TJA.^[13] However, understanding the complexity of treating nonagenarians is necessary because 18.6% of Americans will be aged 85 years and older by 2050.^[6]

As nonagenarians continue to make up a larger percentage of the population, understanding the risk-benefit ratio for TJA is critical. Studies have reported higher complication rates in nonagenarians compared with younger cohorts, and providers and patients may be concerned that nonagenarians may be too frail to undergo elective TJA. The purpose of this study was to assess whether nonagenarians were still at increased risk of complications and hospital readmissions by answering three questions: (1) Do nonagenarians have an increased risk of medical complications after TJA compared with octogenarians and septuagenarians? (2) Do nonagenarians have an increased risk of surgical (orthopaedic-related) complications after TJA compared with octogenarians and septuagenarians? (3) Do nonagenarians have an increased risk of hospital readmission after TJA compared with octogenarians and septuagenarians?

Table 1. Patient Characteristics Among 174 Primary Total Joint Arthroplasty
Factor	Septuagenarians (70–74)	Octogenarians (80–84)	Nonagenarians (90+)	P Value^a
Female	65.5	65.5	65.5	—
Age (yr)	72.0 ± 1.5	82.4 ± 1.4	92.1 ± 1.8	—
Height (inches)	66.5 ± 3.6	65.5 ± 4.0	64.5 ± 4.4	0.029
Weight (pounds)	174.9 ± 34.7	170.6 ± 31.3	146.3 ± 29.9	<0.001
Body mass index (kg/m²)	27.7 ± 4.6	28.0 ± 4.9	24.6 ± 3.6	<0.001
Diagnosis
Osteoarthritis	98.3	98.3	98.3	—
Osteonecrosis	1.7	1.7	1.7	—
ASA score	2.3 ± 0.6	2.5 ± 0.5	2.6 ± 0.5	0.047
Charlson Comorbidity Index	0.6 ± 1.1	0.6 ± 1.0	0.9 ± 1.2	0.266
Major medical comorbidity	36.2	36.2	44.8	0.547

ASA = American Society of Anesthesiologists
Data presented as mean ± SD or %.
^a P value comparing all three groups using chi square or one-way analysis of variance.

Table 2. Medical Complications
Factor	Septuagenarians (70–74) N = 2^a	Octogenarians (80–84) N = 8	Nonagenarians (90+) N = 18^a
Major
Atrial fibrillation		2	2
Acute pacemaker placement			1
Cerebrovascular accident			1
Deep vein thrombosis	1	1	3
Pulmonary embolism		1
Gallstone pancreatitis			1
Rectal bleeding			1
Gastrointestinal bleeding	1
Respiratory stridor	1
Death			2
Minor
Tachycardia		1	1
Chest pain			1
Pneumonia		2
Urinary tract infection		1	1
Fecal impaction			1
Viral gastroenteritis			1
Biliary colic			1
Transient neurologic manifestation			1
Delirium			1
Hyponatremia			1

^aTwo patients had more than one complication.

Table 3. Surgical (Orthopaedic-related) Complications
Factor	Septuagenarians (70–74) N = 6	Octogenarians (80–84) N = 5^a	Nonagenarians (90+) N = 7
Major
Intraoperative fracture		1
Acetabular facture of contralateral hip			1
Dislocation	1
Deep infection	1
Footdrop		1
Peroneal nerve palsy			1
Minor
Cellulitis		2	2
Superficial wound infection	2		2
Fall		1
Laceration to incision after fall			1
Patellar subluxation		1
Lumbar radiculopathy	1
Heterotopic ossification	1

^aOne patient had more than one complication.

Table 4. Complications Among 174 Primary Total Joint Arthroplasty ^a
Factor	Septuagenarians (70–74)	Octogenarians (80–84)	Nonagenarians (90+)	P Value^b
Any complication	12	22	45	<0.001
Major	5	10	21	0.033
Minor	7	12	24	0.025
Medical	3	14	33	<0.001
Major	3	7	17	0.028
Minor	0	7	16	0.006
Orthopaedic	10	9	12	0.830
Major	3	3	3	1.000
Minor	7	5	9	0.765

Data presented as %.
^aOccurring in hospital or within 90 days postoperatively.
^b P value comparing all three groups using the chi square test.

Table 5. Complications Occurring During Each Measurement Time
Factor	Septuagenarians (70–74)	Octogenarians (80–84)	Nonagenarians (90+)	P Value^a
Intraoperatively	0	2	0	0.366
During hospital admission	2	5	16	0.013
After hospital discharge (up to 90 d)	12	17	32	0.022

Data presented as %.
^a P value comparing all three groups using the chi square test.

Table 6. Logistic Regression Analysis for Variables Predicting a Complication
Predictor	Reference Group	Odds Ratio in Comparison With Reference Group	P Value	95% CI
Age group
Octogenarian	Septuagenarian	1.2	0.779	0.4–3.6
Nonagenarian	Septuagenarian	3.1	0.040	1.1–9.3
Joint
TKA	THA	2.2	0.053	1.0–4.9
ASA score	—	1.6	0.256	0.7–3.8
Charlson Comorbidity Index	—	1.4	0.234	0.8–2.4
Major medical comorbidity
Yes	No	1.3	0.663	0.4–5.0
Discharge disposition
Skilled nursing facility	Home	1.9	0.172	0.8–4.5

ASA = American Society of Anesthesiologists, CI = confidence interval, THA = total hip arthroplasty, TKA = total knee arthroplasty
Significant findings (P < 0.05) are shown in bold.