outcomes of complex reconstruction in the elderly curriculum in geriatrics for orthopedic...
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Outcomes of Complex Reconstruction in the Elderly
Curriculum in Geriatrics for Orthopedic Specialists
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Impact on Utilization of Healthcare Resources
Aging of the US society will have a Clear Impact on Practice:
• By 2040: 20% or 77.2 million will be older than 65
• Currently the need for TJR in the elderly is 15/10,000
- 2000: 500K TKR’s
- 2040: 3.48M TKR’s/yr
Artist: C Cornell, M.D. NYC, N.Y.
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Current Orthopedic PracticeOutcomes in the Elderly
• Increasing demand for treatment of age related fractures and degenerative joint disease in patients older than 80 years
• Considerable experience now reported• Purpose:
-To review the results of surgical Rx in this population- To suggest general principles in approaching the elderly patient that needs reconstructive surgery
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Surgical Outcomes in the ElderlyHip Fracture Paradigm
Traditional Wisdom:• Survival and functional
recovery are poor• Preservation of the
femoral head vs arthroplasty is desirable
• Most studies have assumed that the hip fx population is homogeneous
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Fractures of the HipMortality after Treatment
• Increased 1 yr mortality (12-25%) compared to age matched population
• Returns to baseline after 1 yr.
• 5 yr survival is 50%• Survival is best
predicted by pre-injury health status Artist: C Cornell, M.D. NYC, N.Y
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Hip Fracture PopulationPre-injury Health Status
• Recent studies Recent studies clearly demonstrate clearly demonstrate importance of pre-importance of pre-injury health status injury health status on outcomeon outcome
• Fit vs Non-fit Fit vs Non-fit • For example: For example:
Nutritional Status as Nutritional Status as a surrogate for a surrogate for fitnessfitness
JBJS 74A 1992; 74A: 251-260
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Fractures of the HipPredictors of Morbidity and Mortality
• Pre-injury health is the best predictor of outcome
• Within any hip fx pop. are 2 subgroups
- “Fit Elderly”
- “ Frail Elderly”Artist: C Cornell, M.D. NYC, N.Y
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Displaced Femoral Neck FracturesThe “Fit” Elderly Patient
• Definition of “Fit” not a function of age
• Few comobidities (<3)• Independent
community ambulation• Manage their social
affairs• Actively engaged in
sports or social activity
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Hip Fracture Populations
• Not Homogeneous!!• Fit vs. Frail• Treatment must be tailored by patient
characteristics and not diagnosis• Evidenced by comparative outcomes of
ORIF vs Hemiarthroplasty vs THA• Studies by Blomfeldt et al and Healey
clearly demonstrate superiority of THA in “Fit Elderly”
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Outcomes after Femoral Neck Fracture
Blomfeldt, R et al: JBJS 2005; 87A: 1680-1688
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Outcomes after Femoral Neck Fracture
Blomfeldt, R. et al: JBJS 2005; 87A: 1680-1688
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Lessons Learned From Femoral Neck Fractures:
Guidelines for Surgical Care of the Elderly
Pinning is a poor choice for Femoral Neck Fx because:
• Persistent pain• High Re-op Rate• Functional disability
Therefore: Proper Tactic• Procedures with low need for re-op• Pain relief is key• Procedures which permit optimal
functional recovery• THR is the best overall procedure
for the “Fit” elderly patient
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Displaced Femoral Neck Fractures:The Evidenced-Based Algorithm
Femoral Neck Fracture
non-displaced Displaced
< 55 yrs > 55 yrs
pinning in-situ ORIF Fit Pt Frail Pt
2 7.3mm screws THR
WBAT post-op Cemented
Hemi
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Total Joint Arthroplastyin Patients of advanced Age
• In 2000: 1.5% of the pop were older than 85• In 1995: 1.25 million nonagenarians in the USA.In 1995: 1.25 million nonagenarians in the USA.• Currently the need for TJR in the elderly is
15/10,000- 2000: 500K TJR’s- 2040: 3.48M TKR’s/yr
• Incidence of THR in the nonagenarian population: Incidence of THR in the nonagenarian population: 19951995- 136 THR’s per 10,000- 136 THR’s per 10,000- 33,851 performed - 33,851 performed - Mortality rate 2.3%- Mortality rate 2.3%
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Total Joint ArthroplastyThe Octogenarian
Reported Outcomes:• Berend et al ( J Arthroplasty 18;2003)• L’Insalata et al ( J Arthroplasty 7;1992)• Shah et al ( CORR 425:2004 ) Improvement in hip and knee scores is comparable
to younger series Revisions only for infection: TKR higher infection
risk than THR Higher risk of perioperative complications*: longer
hospital stays but low perioperative mortality
* Delerium, MI, Pneumonia, UTI and Decubitius Ulcer
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Total Joint ReplacementThe Octogenarian
Birdsall et al: JBJS 81B: 1999
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Total Joint ReplacementThe Octogenarian
Berend et al: J Arthroplasty 18: 2003
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Total Joint Arthroplasty in The Aged Patient
Special Considerations• Aseptic failure rare• Use constrained
components- non-modular TKR- constrained THR liners
• Bilateral Cases- 83% complications- 16% for unilaterals
• Avoid bilat’s in elderly
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94 y.o. Female unable to walk for 94 y.o. Female unable to walk for 6 months due to hip pain6 months due to hip pain
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94 y.o. female: post-op 94 y.o. female: post-op radiographs after staged THR’sradiographs after staged THR’s
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88 y.o. Retired Chemist: worked 88 y.o. Retired Chemist: worked for Johnson and Johnsonfor Johnson and Johnson
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3 Months after Revision THR 3 Months after Revision THR
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Reconstruction in the ElderlySummary
• Relief of pain and restoration of mobility is achieved with TJR
• Increased but acceptable risk of complications
• “Fit vs Frail” in patient selection• Health quality and survival enhanced• Prosthetic loosening is minimal ( 0%);
consider benefit of constrained components • Avoid doing bilaterals in a single stage