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By Nathan Wei
Arthroplasty (joint replacement surgery) involving the hip and knee is one of the most common orthopedic procedures performed in the United States.
The technology has improved so that a good to excellent outcome is the usual result. Complications and side effects such as postoperative infection, thrombophlebitis (blood clots), loosening of the joint replacement, and persistent pain still occur but fortunately aren’t common.
Patients younger than 50 still are operated on with some reluctance because the chances are quite good that they will require a revision arthroplasty- meaning they will need to have the joint replacement replaced. And the more active a young patient remains, particularly if they abuse the joint replacement, the shorter the life span of the joint prosthesis. Revision of an old joint replacement is a technically difficult procedure.
At the other end of the spectrum, orthopedic surgeons have been reluctant to replace joints in older people, particularly ones that are older than 100 years.
While hip and knee arthroplasty are rarely performed in patients older than 100 years, according to a recently published article, these patients should not be denied the option of this surgery. (Krishnan E, et al. Arthritis Rheum 2007;57:1038-1042).
The authors point out that osteoarthritis (wear and tear arthritis) and hip fracture due to osteoporosis are "two major causes of disability among the older age group."
The researchers examined epidemiologic and mortality data in regards to arthroplasty among people older than 100 years. The comparison group were people in their 90’s.
Adjustments were made for the presence of concurrent illnesses such as congestive heart failure, neurologic diseases, including dementia and stroke, kidney and liver diseases, obesity and other risk factors.
A total of 679 hip arthroplasties were identified among those older than 100 years, compared with 33,975 among people in their 90’s. There were only 7 knee arthroplasties among centenarians, and 2,050 in the nonagenarian (older than 90 but less than 100 year old) group.
Eighty-three percent of 100 year old + patients who underwent arthroplasties were women. Hip fractures were responsible for 94% of hip replacements among nonagenarians and centenarians.
Statistical measurements showed that the 100+ year group had a higher mortality risk than the 90+ year group who underwent a similar procedure.
Hospitalization for hip replacement surgery among those over the age of 100 was associated with a lower risk of death when analyses were performed using the records of all patients older than 100 years. Adjusted mortality rate was less for hip arthroplasty hospitalizations compared with all other causes of hospitalizations combined.
The authors stated that the patients who get joint replacement die less frequently in the post-operative period than comparable patients admitted to the hospital for other reasons. The chief explanation is that the patients are highly selected for joint replacements.
They went on to say that joint replacements for older people will likely to be more frequent in the future, since these operations can improve functional status of elderly patients.
Their conclusion: Joint replacements should not be denied to centenarians because of short-term post-operative life expectancy estimates.
Author’s note: Since demographic data shows that life expectancy is increasing and that people are staying active longer, these findings make a lot of sense. Age itself should not be the determining factor when it comes to joint replacement. Physiological status and overall health is much more important.
Obviously though, the presence of co-morbid conditions (concurrent medical problems) weigh heavily in the mix when it comes to making a decision about this. However, as patients stay healthier, quality of life becomes just as important as longevity in years.
About the Author: Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine. For more info: Arthritis Treatment
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