Knee replacement outcomes and complications in patients in their 80s and 90s
A June 2022 study (1) assessed the mortality and complication rates in 90 year olds and 80 year olds patients total hip and knee replacement patients. The researchers of this study write: “Advancing age is a significant risk factor for the development of perioperative complications and mortality in patients undergoing total hip or knee replacement due to their compromised health status and the associated medical comorbidities. The researchers of this study wanted to identify if 90 year olds having a total hip and knee replacement have a higher incidence of mortality and morbidity compared to 80 year olds).
The researchers found: “Although nonagenarians (90 year olds) undergoing total hip or knee replacement can achieve the same clinical benefit as octogenarians (80 year olds), they have a higher risk of perioperative complications and one-year mortality. Therefore, meticulous preoperative screening, proper patient selection and optimization of comorbidities are essential to minimize any postoperative side effects in patients over 90 years of age.”
Risks of total knee replacement in octogenarians
A January 2022 study (2) examined the risks of total knee replacement in octogenarians and asked “Is age a determining factor in predicting complications?” The researchers write: “There is a direct relationship between the increase in age (older patients) and the prevalence of both functional and cognitive disabling chronic diseases, however, little we know about whether age is an independent factor in predicting worse functional outcomes and readmissions after total knee replacement.” The researchers then determined to evaluate the clinical-functional results and unplanned readmissions within the first 90 postoperative days in patients older than 80 years compared with a control group of patients younger than 80 years. What the researchers found was: “Age as an independent factor proved not to be a predictor (age itself is not a predictor of complication) by itself of unplanned readmissions or worse clinical-functional results in a period of 90 postoperative days between both groups. We believe that the preoperative evaluation of octogenarian patients should be multidisciplinary, with special attention to the identification of comorbidities that can influence the fragility of a patient and the optimization of the pathology.”
Does age matter? Eighty-year-olds and knee replacement
In June 2021 researchers (3) conducted a retrospective observational study in octogenarians who had total knee replacement between 2015 and 2019, comparing preoperative and postoperative Knee Society Score (KSS), Knee Society Function Score (KSFS), extension and flexion balance, and radiologic alignment. In this period 36 patients over the age of 80 years underwent total knee replacement, with a mean age of 81.6 years. Seven patients (19.4%) suffered a medical complication and two patients experienced surgical complications. Four patient died (11.1%) during follow-up. The mean patient survival was 67.4 months. Patients over 80 years did achieve clinical improvement after total knee replacement. Comorbidities, not age, are the burden for surgery in older patients.
A March 2022 study (5) addressed complications, readmission rates, and in-hospital lengths-of-stay in octogenarian vs. non-octogenarians following total knee replacement. This was a study of more than 1.7 million patients. In this research, octogenarians were found to have significantly higher incidence and odds of 90-day readmission rates and significantly longer in-hospital stays compared to controls. Octogenarians also had equal incidence and odds of developing any medical complication and lower incidence and odds of implant-related complications compared to controls.
A September 2023 study (7) analyzed risk factors for surgical treatment decisions in patients over 80 years old. This study compared perioperative complications between groups of patients undergoing primary knee knee replacement, under 60 years old and over 80 years old.
The incidence of surgery-related and systemic complications (eg, urinary tract infections, electrolyte imbalances, and cases of pneumonia), the blood supply and C-reactive protein (CRP) as well as hemoglobin progression were compared between the under 60’s and over 80 patients.
- Data analyses showed age-typical pre-existing conditions, especially arterial hypertension, showed a significant association with the occurrence of systemic complications. In addition, high postoperative CRP values in elderly patients revealed an association to systemic complications.
However, the study shows that primary cemented knee arthroplasty is a safe procedure without an increased incidence of surgical complications, even in elderly patients. The increased incidence of internal complications in octogenarians, in turn, should receive more attention in the perioperative course.
Same-day discharge in knee replacement patients 80 years old and up
A March 2022 study (4) looked at same-day discharge in knee replacement patients 80 years old and up. The researchers of this paper say “the purpose of this study was to compare 90-day complications and mortality following same-day discharge after primary total knee replacement in patients more than 80 years old and those under 80 years old. Patients who underwent unilateral primary total knee replacement, were discharged same day, and had a minimum 90-day follow-up were examined. These patients were stratified into two cohorts based upon age: (1) nonoctogenarians (<80 years old) and (2) octogenarians (≥80 years old). In total, 1,111 patients were included in each group.
Findings:
- There was no significant difference in 90-day mortality between the two groups. However, octogenarians were at significantly increased risk of postoperative atrial fibrillation, nonatrial fibrillation arrhythmias, pneumonia, stroke, heart failure, and urinary tract infection compared with the nonoctogenarian cohort. Relative to matched controls, octogenarians were at significantly increased risk of numerous 90-day medical complications following same-day primary primary total knee replacement, including cardiopulmonary complications, stroke, and urinary tract infection.
“The indication for total knee replacement, especially with a PS implant, may be encouraged in appropriately selected elderly patients.”
An April 2023 report (6) from Lyon University Hospital researchers compared implant survivorship and functional outcomes between elderly patients (those over 80 years old) and younger patients (those 60-75 years old) following total knee replacement, using a single modern posterior-stabilized (PS) prosthetic design. (A prosthetic that takes over the function of the posterior cruciate ligament in holding the thigh to the shin bone to prevent the thigh from slipping forward over the shin bone.)
- At a minimum of 5-year follow-up, there was no revision surgery and a very low rate of complications requiring reoperations both in the group over 80 years of age and in the younger population, with the use of a PS prosthesis.
- The functional results were slightly lower for elderly patients and correlate with the lower functional demands of this population. The indication for TKA, especially with a PS implant, may be encouraged in appropriately selected elderly patients.
- At last follow-up, data were available for 41 knees in the elderly group (including 17 patients who died before 5-year follow-up) and 123 knees in the younger group.
The researchers concluded: “The indication for total knee replacement, especially with a PS implant, may be encouraged in appropriately selected elderly patients.”
References
1 Kitridis D, Tsikopoulos K, Givissis P, Chalidis B. Mortality and complication rates in nonagenarians and octogenarians undergoing total hip and knee arthroplasty: a systematic review and meta-analysis. European Geriatric Medicine. 2022 Jan 24:1-9.
2 Vildoza S, García-Mansilla A, Brandariz R, Holc F, Teves JI, Carbó L, Costantini J. Total knee replacement in octogenarians, Is age a determining factor in predicting complications? a retrospective cohort study. European Journal of Orthopaedic Surgery & Traumatology. 2022 Jan 5:1-5.
3 Trigueros-Larrea JM, Gonzalez-Bedia MA, Lomo-Garrote JM, Martin-de la Cal O, Martin-Ferrero MA. Total knee arthroplasty in octogenarians: should we still be so restrictive?. Geriatrics. 2021 Jun 30;6(3):67.
4 Berger PZ, Gu A, Fassihi SC, Stake S, Bovonratwet P, Gioia C, Palosaari A, Campbell JC, Thakkar SC. Increased Complications in Octogenarians Undergoing Same-Day Discharge following Total Knee Arthroplasty: A Matched Cohort Analysis. The Journal of Knee Surgery. 2022 Mar 8.
5 Varghese PP, Chen C, Gordon AM, Magruder ML, Vakharia RM, Erez O, Razi AE. Complications, readmission rates, and in-hospital lengths-of-stay in octogenarian vs. non-octogenarians following total knee arthroplasty: An analysis of over 1.7 million patients. The Knee. 2022 Mar 1;35:213-9.
6 Deroche E, Batailler C, Shatrov J, Gunst S, Servien E, Lustig S. Similar survival rate but lower functional outcomes following TKA in the elderly people compared to younger patients: analysis of a posterior stabilised implant with minimum 5-year follow-up. Knee Surgery, Sports Traumatology, Arthroscopy. 2023 Apr;31(4):1470-6.
7 Koettnitz J, Isbeih J, Peterlein CD, Migliorini F, Götze C. A Comparative Analysis of Perioperative Complications in Octogenarians and Patients under 60 Years of Age after Primary Cemented Total Knee Arthroplasty. Clinical Medicine & Research. 2023 Sep 1;21(3):136-43.
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