Age as an independent risk factor for postoperative morbidity and mortality after total joint arthroplasty in patients 90 years of age or older

Comparison of Postoperative Outcomes of Patients Undergoing Total Hip and Total Knee Arthroplasty Following a Diagnosis of Dementia: A TriNetX Database Study

Background

As life expectancy improves for patients with dementia, the demand for mobility-improving surgeries such as total joint arthroplasty (TJA) will increase. There is little research on patients with dementia undergoing TJA, although dementia has been shown to be a risk factor for complications. The purpose of this study is to compare postoperative outcomes of patients with dementia undergoing TJA at 90 days, 2 years, and 5 years.

Methods

The TriNetX database was retrospectively queried for all patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients were divided into cohorts by preoperative diagnosis of dementia and propensity score matched. The following outcomes were evaluated between groups at 90 days, 2 years, and 5 years postoperatively: revision, resection arthroplasty, closed reduction (THA only), femur fracture plating, and prosthetic joint infection. Readmission and manipulation under anesthesia (TKA only) were evaluated at 90 days postoperatively. Univariate and multivariate analyses were performed.

Results

After matching, there were no differences in demographics or comorbidities between groups. TKA (odds ratio [OR] = 1.75, 95% confidence interval [CI] 1.42-2.15, P < .001) and THA (OR = 2.17, 95% CI 1.92-2.45, P < .001) patients with dementia were more likely to be readmitted than patients without dementia. At 2 years (OR = 2.07, 95% CI 1.14-3.77, P = .015) and 5 years (OR = 2.14, 95% CI 1.32-3.48, P = .002) postoperatively, THA patients with dementia were more likely to have proximal femur fracture plating than patients without dementia.

Conclusions

Patients undergoing THA with dementia had worse outcomes than patients undergoing THA without dementia and TKA with dementia. The overall rate of complications was low, and a diagnosis of dementia should not be an absolute contraindication to proceeding with TJA.

In-hospital outcomes following primary and revision total hip arthroplasty in nonagenarian patients

PURPOSE

The primary goal of this study was to assess the risk of postoperative surgical and medical complications and problems among nonagenarian patients operated with hip arthroplasty.

METHODS

Data from a specific high-volume arthroplasty clinic, were collected to evaluate postoperative morbidity and complication rates after hip arthroplasty in nonagenarians, compared with a control group of younger, but similar patients. Outcomes evaluated included length of stay, transfusion rate, and postoperative medical and surgical complication rates.

RESULTS

A total of 97 nonagenarian patients (mean age 91.4 years) were included, and compared with 89 control group patients (mean age 70.18 years). Nonagenarian patients had significantly longer length of stay (11.44 vs. 7.98 days, p < 0.01), significantly higher risk of needing a transfusion (11.30% vs. 3.40%, p = 0.04), and significantly higher risk of a postoperative medical complication (28.90% vs. 11.20%, p = 0.03). There was no difference in postoperative surgical complication rate (7.20% vs. 2.20%, p = 0.12).

CONCLUSION

Nonagenarian patients, when compared to a younger control group, experience significantly longer hospital stays, and risk of non-surgical complications. Arthroplasty in nonagenarian patients carries with it a high risk of complications, and thus careful pre-operative evaluation and the care of these patients at high volume, specialized clinics is important to optimize outcomes.

LEVEL OF EVIDENCE

Level III retrospective cohort analysis.

A comprehensive analysis of age and 30-day complications following total shoulder arthroplasty: nonagenarians, octogenarians, and septuagenarians

Background

Increased age is a well-known risk factor for development of osteoarthritis. Total shoulder arthroplasty (TSA) is a common treatment option for patients with severe glenohumeral osteoarthritis. The purpose of this study was to investigate the association between the septuagenarian, octogenarian, and nonagenarian populations and postoperative outcomes following TSA.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015 and 2020. Patients were divided into cohorts based on age: sexagenarians (60-69), septuagenarians (70-79), octogenarians (80-89), and nonagenarians (90+). Multivariate logistic regression was used to identify associations between age and postoperative complications.

Results

On bivariate analysis, compared to sexagenarians, septuagenarians were significantly associated with higher rates of myocardial infarction (P = .038), blood transfusion (P < .001), organ/space surgical site infection (P = .048), readmission (P = .005), and nonhome discharge (P < .001. Compared to septuagenarians, octogenarians were significantly associated with higher rates of urinary tract infection (P < .001), blood transfusion (P < .001), readmission (P = .002), non-home discharge (P < .001), and mortality (P = .027). Compared to octogenarians, nonagenarians were significantly associated with higher rates of sepsis (P = .013), pneumonia (P = .003), reintubation (P = .009), myocardial infarction (P < .001), blood transfusion (P < .001), readmission (P = .026), nonhome discharge (P < .001), and mortality (P < .001).

Conclusion

From age 60, each decade of age was identified to be an increasingly significant predictor for blood transfusion, readmission, and nonhome discharge following TSA. From age 70, each decade of age was additionally identified to be an increasingly significant predictor for mortality.

Is Discharge Within a Day Following Total Hip Arthroplasty Safe in the Septuagenarian and Octogenarian Population? A Propensity-Matched Cohort Study

BACKGROUND

Limited data exists on whether patients older than 70 can safely be discharged within a day (rapid discharge (RD)) following primary total hip arthroplasty (THA). The purpose of this study was to compare perioperative complications and readmission rates associated with RD in patients ≥70 years compared to longer lengths of stay following THA.

METHODS

A retrospective, propensity-matched cohort study was conducted using the National Surgical Quality Improvement Program database from 2006 to 2020. Patients ≥70 years undergoing RD following THA were propensity matched to patients ≥70 years who had longer hospital stays (nonrapid discharge). Sub-analyses were performed for septuagenarians and octogenarians. Following 1:1 matching, multivariate analyses were performed to compare perioperative complications and readmissions. Following propensity matching, both groups contained 2,192 patients.

RESULTS

The RD patients were found to have shorter operative times (P < .001), less bleeding complications (P < .001), and were more likely to have home discharges (P < .001). The 2 cohorts did not differ in the remaining complications or 30-day postoperative period readmissions among all patients and when evaluating septuagenarians and octogenarians.

CONCLUSION

Patients ≥70 years undergoing RD following THA had comparable complication and readmission rates to patients older than 70 undergoing nonrapid discharge. Furthermore, RD patients were more likely to have home discharges and have shorter operations with less bleeding complications. Septuagenarians receiving RD were more likely to have an unplanned readmission. These data suggest that RD following THA can be performed safely in select patients older than 70.

Hip Fractures in Centenarians: Functional Outcomes, Mortality, and Risk Factors from a Multicenter Cohort Study

Background

Increasing longevity has caused the very old population to become the fastest-growing segment. The number of centenarians (over 100 years old) is increasing rapidly. Fractures in the elderly lead to excessive medical costs and decreased quality of life with socioeconomic burdens. However, little research has thoroughly examined the functional outcomes and mortality of hip fractures in centenarians.

Methods

This is a retrospective observational study. Sixty-eight centenarian hip fracture patients were admitted to the 10 institutions from February 2004 to December 2019. Fifty-six patients with 1-year follow-up were finally included. The following data were obtained: sex, age, body mass index, Charlson comorbidity index value on the operation day, Koval's classification for ambulatory ability, type of fracture, the time interval from trauma to surgery, American Society of Anesthesiologists grade, surgery-related complications, and duration of hospital stay. Postoperative Koval's classification (at 1 year after surgery) and information about death were also collected. Multivariate analysis was performed to analyze the risk factors affecting mortality 1 year after surgery.

Results

Mortality rates were 26.8% at 6 months and 39.3% at 1 year. The 90-day mortality was 19.6%, and one of them (2.1%) died in the hospital. The 1-year mortality rates for the community ambulatory and non-community ambulatory groups were 29% and 52%, respectively. Only 9 (16.1%) were able to walk outdoors 1 year after surgery. The remaining 47 patients (83.9%) had to stay indoors after surgery. Multivariate analysis demonstrated that the pre-injury ambulatory level (adjusted hazard ratio, 2.884; p = 0.034) was associated with the risk of mortality.

Conclusions

We report a 1-year mortality rate of 39.3% in centenarian patients with hip fractures. The risk factor for mortality was the pre-injury ambulatory status. This could be an important consideration in the planning of treatment for centenarian hip fracture patients.

Same-Day Discharge Total Knee Arthroplasty in Octogenarians

BACKGROUND

One of the most important aspects of the transition to outpatient (OP) arthroplasty is patient selection, with guidance traditionally recommending that OP total knee arthroplasty (TKA) be reserved for patients <80 years old. However, there are limited data as to whether older age should really be considered a contraindication to OP-TKA. The purpose of this study is to assess the risk of complications and readmissions following OP-TKA in patients ≥80 years old.

METHODS

This is a retrospective, propensity-matched cohort study of the National Surgical Quality Improvement Program database from 2011 to 2019. Patients ≥80 years undergoing OP (same-day discharge) TKA were propensity matched to patients ≥80 years undergoing inpatient (IP) TKA based on age, gender, race, body mass index, American Society of Anesthesiologists classification, functional status, smoking status, anesthetic type, and medical comorbidities. There were 1,418 patients (709 IPs and 709 OPs) included. All baseline factors were successfully matched between IP-TKA versus OP-TKA (P ≥ .18 for all). Thirty-day complications, readmissions, reoperations, and mortality were subsequently analyzed.

RESULTS

Thirty-day readmission rates were identical between patients undergoing IP-TKA and OP-TKA (3.5% versus 3.5%, P = 1.0). Similarly, there was no significant difference in the incidence of major complications (2.7% versus 2.0%, P = .38), reoperations (1.3% versus 0.8%, P = .44), or mortalities (0.3% versus 0.3%, P = 1.0) within 30 days.

CONCLUSION

Octogenarians undergoing OP-TKA had comparable complication rates to similar patients undergoing IP-TKA. OP-TKA can be performed safely in select octogenarians and age ≥80 years likely does not need to be a uniform contraindication to OP-TKA.

Hip and Knee Arthroplasty Outcomes for Nonagenarian Patients

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.

Nonagenarians and Octogenarians Undergoing THA and TKA: A 10-Year Age Difference Increases Rates of In-Hospital Complications But Does Not Affect 90-Day Outcomes

Background

The population of nonagenarians undergoing total joint arthroplasty (TJA) of the hip or knee is expected to increase, but this population may be reluctant to consider elective surgery because of their advanced age.

Purpose

We sought to compare TJA outcomes between nonagenarians and octogenarians with an exact 10-year age difference.

Methods

We performed a retrospective chart review, including 129 nonagenarians who underwent primary unilateral TJA for osteoarthritis in a 4-year period at a single institution and who were matched with 381 octogenarians based on sex, body mass index, Charlson Comorbidity Index, replaced joint (hip or knee), and a 10-year age difference. Ninety-day outcomes included Centers for Medicare and Medicaid Services (CMS) defined complications, unscheduled outpatient clinic visits, emergency room (ER) visits, and readmissions. No patients were lost to follow-up.

Results

Nonagenarians and octogenarians had comparable rates of CMS complications (10% vs 6.3%, respectively), but nonagenarians had higher rates of CMS mechanical complications (6.2% vs 1.6%). There was 1 death in each group. Nonagenarians had longer hospital stays than octogenarians (4.1 vs 3.0 days, respectively), and a greater risk of in-hospital events and complications (60.5% vs 37.3%, respectively). The groups showed similar rates of unscheduled outpatient visits (14.7% vs 13.9%, respectively), ER visits (12.4 vs 6.6%, respectively), and readmissions (6.2% vs 7.1%, respectively).

Conclusions

This retrospective study found higher rates of in-hospital complications in nonagenarians than in matched octogenarians following elective TJA, although the 2 groups showed similar rates of postdischarge complications. Further research in a larger cohort is needed.

Is there a difference in mobility and inpatient physical therapy need after primary total hip and knee arthroplasty? A decade-by-decade analysis from 60 to 99 years

INTRODUCTION

Extended inpatient rehabilitation (PT) after total hip (THA) and knee arthroplasty (TKA) has a significant impact on total care costs. As patients age, extended PT might be required following THA and TKA. This study examined the relationship between patient age, functional mobility, inpatient PT need, and discharge disposition in THA and TKA patients.

MATERIALS AND METHODS

This retrospective study included patients aged 60 + undergoing primary THA or TKA between 2018 and 2020 at an orthopedic hospital. Comparing by age-decade, 7374 (3600 THA, 3774 TKA) sexagenarians, 5350 (2367 THA, 2983 TKA) septuagenarians, 1356 (652 THA, 704 TKA) octogenarians, and 78 (52 THA, 26 TKA) nonagenarians were analyzed. We compared the number of PT sessions needed for discharge clearance and the postoperative functional mobility using the Activity Measure for Post-Acute Care (AM-PAC) tool. Statistical analyses included ANOVA with post-hoc Tukey's HSD for continuous data and Chi-squared test for categorical variables.

RESULTS

The number of PT sessions required for discharge clearance increased with age after THA (3.3 ± 1.9 sessions vs 3.8 ± 2.1 vs 5.0 ± 2.7 vs 6.2 ± 3.0; p < 0.01) and TKA (4.0 ± 2.1 vs 4.7 ± 3.1 vs 5.2 ± 2.8 vs 5.0 ± 1.6; p < 0.01). The functional mobility improvement as measured by AM-PAC was significantly lower for nonagenarians after THA (4.9 ± 2.8 vs 5.1 ± 2.8 vs 4.6 ± 3.3 vs 3.3 ± 3.9; p < 0.01) and TKA (5.0 ± 2.9 vs 4.7 ± 3.2 vs 3.9 ± 3.4 vs 3.2 ± 2.6; p < 0.01).

CONCLUSION

Patients in their eighth and ninth decade had less improvement in functional mobility during in-hospital rehabilitation and utilized more PT services. However, clinical results in the elderly are still satisfying and the data may be helpful for resource utilization planning and risk-adjustment in value-based payment models.

Elective Total Hip Arthroplasties in Nonagenarians-Age Does Matter: A National Surgical Quality Improvement Program Study

BACKGROUND

The aim of this study is to assess the independent effect of age on the risk of postsurgical complications and death in patients undergoing total hip arthroplasty (THA).

METHODS

The National Surgical Quality Improvement Program was used to identify all patients aged 65 years and older who underwent primary THA from 2011 to 2017. Study outcomes were minor complications, major life-threatening complications, and 30-day mortality. Predictors of outcomes were identified using bivariate analyses and age was added into the final logistic regression models with stepwise selection.

RESULTS

A total of 74,361 patients were included in the analysis. Mean (standard deviation) age was 735 years (6.46), median 72.0 years; 1,119 (1.50%) patients were ≥90 years. Females comprised 60.6% of the patient sample. The incidence of major life-threatening complications, minor complications, and death was 939/74,361 (1.3%), 2,098 (2.8%) and 154 (0.2%) respectively. When added to the final models, age was significantly associated with an increased risk of postoperative complications and mortality.

CONCLUSION

Elective THA in relatively healthy nonagenarians should only be considered among patients with disabling osteoarthritis demonstrating a restricted quality of life. Although THA can substantially improve patient wellbeing, our findings suggest that surgeons and patients must consider the impact of age on patient course and outcomes regardless of the presence of comorbidities.

LEVEL OF EVIDENCE

Level II, prognostic study.

Blood Management Following Total Joint Arthroplasty in an Aging Population: Can We Do Better?

BACKGROUND

To evaluate the transfusion rates for octogenarians and nonagenarians following total knee and hip arthroplasty (TKA, THA), we compared transfusion rates and associated risk factors among sexagenarians, septuagenarians, octogenarians, and nonagenarians.

METHODS

This retrospective cohort study included 13,603 sexagenarians, 9796 septuagenarians, 2706 octogenarians, and 158 nonagenarians that received a primary, unilateral THA or TKA between 2016 and 2020 at a high-volume institution. Using multivariable logistic regression analysis, the study analyzed risk factors for postoperative transfusions including use of tranexamic acid (TXA) and compared preoperative and postoperative hemoglobin (Hgb) levels and the drop in Hgb.

RESULTS

Nonagenarians had significantly higher transfusion rates (THA 25.5%, TKA 26.7%) than octogenarians (THA 9.9%, TKA 9.2%), septuagenarians (THA 3.3%, TKA 4.5%), and sexagenarians (THA 1.9%, TKA 2.9%) (P < .01). Significant risk factors for transfusion requirement following THA were American Society of Anesthesiologists level III (odds ratio [OR] 5.3, P < .01) and American Society of Anesthesiologists level IV (OR 8.0, P = .01), nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), longer duration of surgery (OR 1.0, P < .01), and hepatopathy (OR 3.1, P < .01). Significant risk factors following TKA were nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01; combined: OR 0.2, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), and longer surgery time (OR 1.0, P < .01).

CONCLUSION

The strongest independent risk factors for increased transfusion rates among octogenarians and nonagenarians were lack of TXA application and lower preoperative Hgb levels. Routine TXA application and preoperative patient optimization are recommended to reduce transfusion rates in patients aged 80+.

Primary total hip arthroplasty in patients older than 90 years of age - a retrospective matched cohort study

INTRODUCTION

Advanced age is considered a major risk factor for postoperative complications in total hip arthroplasty (THA). Consequently, older patients undergoing THA may require more detailed pre-procedural examinations and more healthcare resources postoperatively than younger patients. The purpose of this study was to compare discharge parameters and complication rates of THA in patients ⩾90 years old to those <90 years old.

METHODS

A retrospective review of 14,824 THA patients from 2011 to 2021 at a high-volume, urban academic centre was conducted. Patients ⩾90 years old were propensity-matched to a control group of patients aged <90 years old. Patient demographics, surgical time, hospital length of stay (LOS), discharge disposition, and 90-day revision, readmission, and mortality rates were collected. Demographic differences and outcomes were assessed using chi-square and independent sample t-tests.

RESULTS

After propensity matching, the average age in the younger cohort (YC, n = 54) was 75.81 ± 7.89, and 91.61 ± 1.73 for the older cohort (OC, n = 54). The OC had a longer LOS than the YC (mean 3.90 vs. 3.06 days; p = 0.031). Discharge disposition significantly differed (p = 0.007); older patients were more likely to be discharged to skilled nursing facilities (33.3% vs. 14.8%) or acute rehabilitation centres (14.8% vs. 3.7%) and less likely to be discharged to prior place of residence (home self-managed/home with services, 51.9% vs. 79.6%). There was no significant difference in surgical time (93.87 ± 29.75 vs. 96.09 ± 26.31 min; p = 0.682), 90-day revision rate (3.7% vs. 0%; p = 0.153), 90-day readmission rate (9.4% vs. 3.7%; p = 0.543), and 90-day mortality rate (1.9% vs. 1.9%; p = 1.000).

CONCLUSIONS

Although THA patients over 90 years of age had a longer LOS and differing discharge disposition, these patients had similar complications compared to their younger counterparts. Thus, our study supports similar efficacy of THA in patients 90 years and older relative to younger THA candidates.

Contemporary Mortality Rate and Outcomes in Nonagenarians After Primary Total Knee Arthroplasty

BACKGROUND

Nonagenarians (90-99 years) have experienced the fastest percent growth in primary total knee arthroplasty (TKA) utilization recently. However, there are limited data on the results of the procedure in this population. The goals of this study are to determine the mortality rate, implant survivorship, clinical outcomes, and complications of primary TKAs in nonagenarians.

METHODS

Our institutional total joint registry was used to identify 105 nonagenarians who underwent 119 primary cemented TKAs for osteoarthritis between 1997 and 2017. Mean age was 92 years, with 58% being female. Mortality, revision, and reoperation were assessed using cumulative incidence with death as a competing risk and Cox regression methods. Clinical outcomes were assessed using Knee Society Scores. A posterior-stabilized design was used in 88%. Mean follow-up was 4 years.

RESULTS

The mortality rates were 0%, 2%, 9%, and 47% at 90 days, 1 year, 2 years, and 5 years, respectively. The 5-year cumulative incidences of any revision and reoperation were 0% and 3%, respectively. The reoperations included 2 internal fixations for periprosthetic fracture and 1 hardware removal. The mean Knee Society Score improved significantly from 34 preoperatively to 80 at 5 years (P < .001). The 5-year cumulative incidence of any nonmortality complication was 66%. The most common complications were urinary tract infections and retention (8%) in the early postoperative period, and acquired idiopathic stiffness (10%) later.

CONCLUSION

Nonagenarians undergoing primary TKA had low mortality rates at 90 days (0%) and 1 year (2%) with substantial functional improvements. The cumulative incidences of revision and reoperation were low at 5 years.

LEVEL OF EVIDENCE

Level IV, retrospective cohort.

Short-Term Outcomes After Total Shoulder Arthroplasty in Octogenarians: A Matched Analysis

Introduction

Studies have shown that the use of total shoulder arthroplasty is increasing every year in the United Stated at a rate higher than that of total hip or total knee arthroplasty. As the population of the United States continues to age, it is becoming more important for surgeons to understand the true impact of age on outcomes and complications following procedures such a total shoulder arthroplasty. The purpose of this study was to determine if octogenarians have poorer outcomes after total shoulder arthroplasty compared to a younger, matched control group.

Methods

Data was obtained through the American College of Surgeons National Surgical Quality Improvement Program database (ACS NSQIP). Patients who had undergone total shoulder arthroplasty were identified by Current Procedural Terminology code (23472). Indication for arthroplasty was determined by ICD9/10 code (osteoarthritis, fracture, other). Each octogenarian was matched 1:1 to a non-octogenarian based on sex, BMI, ASA class, medical comorbidities, functional status, and surgical indication for arthroplasty by propensity scoring. A subgroup analysis was performed to compare outcomes between only those patients who underwent TSA for osteoarthritis.Outcomes of interest were assessed between the two groups for statistical significance using a chi-squared test or fisher exact test for expected values of less than 5. Statistical significance was set at p<0.05.

Results

After matching, octogenarians were found to be at higher risk of readmission (4.7% vs. 3.3%, p=0.046), non-home discharge (27.1% vs. 9.4%, p<0.001), and overall surgical (4.4% vs. 2.5%, p=0.006) and medical complications (3.7% vs. 2.4%, p=0.039). In the setting of TSA for osteoarthritis only, however, octogenarians were only at higher risk for non-home discharge (22.4% vs. 7.5%, p<0.001).

Conclusions

Octogenarians are at higher risk of some complications following total shoulder arthroplasty but fewer than has been previously reported, particularly in the setting of arthroplasty for the treatment of arthritis.

The Changing Characteristics of Arthroplasty Patients: A Retrospective Cohort Study

BACKGROUND

Total joint arthroplasty (TJA) is among the most common operations performed worldwide, with global volumes on the rise. It is important to understand if the characteristics of this patient population are changing over time for resource allocation and surgical planning. The purpose of this study is to examine how this patient population has changed between 2003 and 2017.

METHODS

A retrospective review of a prospective TJA database was conducted. Age, gender, body mass index, comorbidities, American Society of Anesthesiologists class, responsible diagnoses, and comorbidities were compared over 5-year intervals between 2003 and 2017. All patients undergoing primary, elective TJA were included.

RESULTS

Overall, 17,138 TJAs were included. Mean body mass index increased over the study period for total hip arthroplasty (THA; 29.4-30.4 kg/m², P < .0001) and total knee arthroplasty (TKA; 32.0-3.1 kg/m², P < .0001) patients. THA patients were significantly younger in more recent years (68.0-66.8 years old, P = .0026); this trend was not observed among TKA patients. Over the study period, a significantly higher proportion of patients were American Society of Anesthesiologists class III/IV for THA (50.5%-72.3%) and TKA (57.5%-80.7%) (P < .00001). Prevalence of common comorbidities did not change significantly.

CONCLUSION

The key findings of this retrospective analysis of a large prospective database are that patients undergoing TJA are becoming younger and more obese. It is unclear whether patients are becoming more medically complex. These trends paint a concerning picture of a population that is increasingly complex, and may require a greater allocation of resources in the future.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Mortality After Revision Total Hip Arthroplasty

BACKGROUND

In counseling patients about the complications of revision total hip arthroplasty (revTHA), it is imperative that mortality be considered. The actual mortality rate by indication of revision is ill-defined. The purpose of this study is to determine the mortality rate after revTHA.

METHODS

An institutional database identified 596 patients who had undergone revTHA between 2012 and 2018. Medical records, national, state, and local death indexes were queried for mortality status and indication for revTHA. For survivors, the last clinical visit date was used for censoring in the mortality analysis. Mortality rates were calculated for all clinical patients and then by specific indication for revision.

RESULTS

The overall 2-year mortality rate following revTHA was 19.5 deaths per 1000 or 1 in 51 patients. Patients presenting with a periprosthetic fracture had a significantly higher 2-year mortality rate of 74.5 deaths per 1000 or 1 in 13 patients (P < .001), while an indication of dislocation or instability had a slightly higher 2-year mortality rate of 50.3 per 1000 (1 in 20) but this difference was not significant (P = .531). Other indications such as mechanical loosening or infection did not have a significantly different mortality rate.

CONCLUSION

The overall 2-year mortality rate following revTHA was 19.5 deaths per 1000 which was largely attributed to patients with a periprosthetic fracture (74.5 per 1000) with other indications not significantly impacting mortality. Mortality rates and specific rates by indication for revision should be considered when counseling patients prior to revTHA.

Contemporary Mortality Rate and Outcomes in Nonagenarians Undergoing Primary Total Hip Arthroplasty

BACKGROUND

Nonagenarians (90-99 years) have experienced the fastest percent growth in primary THA utilization recently. However, there are limited data on this population. This study aimed to determine the mortality rate, implant survivorship, clinical outcomes, and complications of primary THAs in nonagenarians.

METHODS

Our institutional total joint registry was used to identify 144 nonagenarians who underwent 149 primary THAs for osteoarthritis only between 1997 and 2017. The mean age was 92 years, with 63% being female. Mortality, revision, and reoperation were assessed using cumulative incidence with death as a competing risk and Cox regression methods. Clinical outcomes were assessed using Harris hip scores (HHSs). Cemented femoral components were used in 68%. The mean follow-up was 4 years.

RESULTS

The mortality rates were 6%, 8%, 14%, and 49% at 90 days, 1 year, 2 years, and 5 years, respectively. The 5-year cumulative incidences of any revision and reoperation were 1% and 4%, respectively. The mean HHS improved significantly from 48 preoperatively to 76 at 5 years (P < .001). The 5-year cumulative incidence of any complication was 69%, with the most common being periprosthetic femur fracture (7) intraoperatively, delirium (25) early postoperatively, and periprosthetic femur fracture (10) later postoperatively. Uncemented stem fixation was associated with a higher risk for intraoperative femur fracture (Hazard ratio 5, P = .04) but not with a higher 5-year periprosthetic postoperative femur fracture risk (P = .19).

CONCLUSION

Nonagenarians undergoing primary THA had substantial mortality rates at 90 days (6%) and 1 year (8%). While the cumulative incidence of any revision and reoperations were low at 5 years, the high complication rate is mostly due to periprosthetic fractures.

LEVEL OF EVIDENCE

Level IV, retrospective cohort.

Differences in Hospital Costs among Octogenarians and Nonagenarians Following Primary Total Joint Arthroplasty

The proportion of patients over the age of 90 years continues to grow, and the anticipated demand for total joint arthroplasty (TJA) in this population is expected to rise concomitantly. As the country shifts to alternative reimbursement models, data regarding hospital expenses is needed for accurate risk-adjusted stratification. The aim of this study was to compare total in-hospital costs following primary TJA in octogenarians and nonagenarians, and to determine the primary drivers of cost. This was a retrospective analysis from a single institution in the U.S. We used time-drive activity-based costing (TDABC) to capture granular total hospital costs for each patient. 889 TJA’s were included in the study, with 841 octogenarians and 48 nonagenarians. Nonagenarians were more likely to undergo total hip arthroplasty (THA) (70.8% vs. 42.4%; p < 0.0001), had higher ASA classification (2.6 vs. 2.4; p = 0.049), and were more often privately insured (35.4% vs. 27.8%; p = 0.0001) as compared to octogenarians. Nonagenarians were more often discharged to skilled nursing facilities (56.2% vs. 37.5%; p = 0.0011), experienced longer operating room (OR) time (142 vs. 133; p = 0.0201) and length of stay (3.7 vs. 3.1; p = 0.0003), and had higher implant and total in-hospital costs (p < 0.0001 and 0.0001). Multivariate linear regression showed implant cost (0.700; p < 0.0001), length of stay (0.546; p < 0.0001), and OR time (0.288; p < 0.0001) to be the strongest associations with overall costs. Primary TJA for nonagenarians was more expensive than octogenarians. Targeting implant costs, length of stay, and OR time can reduce costs for nonagenarians in order to provide cost-effective value-based care.

Is there an optimal age for total knee arthroplasty?: A systematic review

PURPOSE

The purpose of this systematic review was to elucidate the optimal age for patients undergoing total knee arthroplasty (TKA), to optimize the balance between the benefits and risks by analyzing patient-reported outcome measurements (PROM), revision rate, and mortality according to age.

MATERIALS AND METHODS

A rigorous and systematic approach was used and each of the selected studies was evaluated for methodological quality. Data were extracted according to the following: study design, patients enrolled, patient age at the time of surgery, follow-up period, PROM, revision rate, and mortality.

RESULTS

Thirty-nine articles were included in the final analysis. The results were inconsistent in the PROM analysis, but there was consensus that PROM were good in patients in their 70s . In the revision rate analysis, there was consensus that the revision rate tends to increase in TKA in younger patients, but no significant difference was observed in patients > 70 years of age. In the mortality analysis, there was consensus that the mortality was not significantly different in patients < 80 years of age, but tended to increase with age.

CONCLUSION

This systematic review shows that the PROM were good when TKA was performed in patients between 70 and 80 years of age; the best PROM could be achieved around 70 years of age, and no significant difference in the revision or mortality rates was observed between 70 and 80 years of age; however, mortality tended to increase with age. Therefore, the early 70s could be recommended as an optimal age to undergo TKA.

Operative Fixation of Hip Fractures in Nonagenarians: Is It Safe?

BACKGROUND

With the shift in hip fracture epidemiology toward older individuals as well as the shift in demographics toward nonagenarians, it is important to understand the outcomes of treatment for these patients.

METHODS

Geriatric patients (≥65 years old) who underwent surgery for hip fracture were identified in the 2005-2017 National Surgical Quality Improvement Program database and stratified into 2 age groups: <90 and ≥90 years old (nonagenarians). Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for complications and 30-day readmissions. Risk factors for serious adverse events (SAEs) and 30-day mortality in nonagenarians were characterized.

RESULTS

This study included 51,327 <90 year olds and 15,798 nonagenarians. Overall rate of SAEs in nonagenarians was 19.89% while in <90 year olds was 14.80%. Multivariate analysis revealed higher risk for blood transfusion (relative risk [RR] = 1.21), death (RR = 1.74), pneumonia (RR = 1.24), and cardiac complications (RR = 1.33) in nonagenarians (all P < .001). Risk factors for SAEs in nonagenarians include American Society of Anesthesiologists ≥3, dependent functional status, admitted from nursing home/chronic/intermediate care, preoperative hypoalbuminemia, and male gender (all P < .05), but not time to surgery (P > .05). In fact, increased time to surgery in nonagenarians was associated with lower risk of 30-day mortality (RR = 0.90, P = .048).

CONCLUSION

Overall complication risk after hip fracture fixation in nonagenarians remains relatively low but higher than their younger counterparts. Interestingly, since time to surgery was not associated with adverse outcomes in nonagenarians, the commonly accepted 48-hour operative window may not be critical to this population. Additional time for preoperative medical optimization in this vulnerable population appears prudent.

Hip Fracture in Nonagenarians: Characteristics and Factors Related to 30-Day Mortality in 1177 Patients

BACKGROUND

The number of nonagenarian patients with hip fracture is increasing. The goals of this study were to describe the characteristics and in-hospital course of a cohort of 1177 nonagenarians admitted for hip fracture compared with younger patients and to identify risk factors for 30-day mortality after admission.

METHODS

This is a retrospective observational cohort study including patients aged 65 years or older admitted for hip fracture during various periods from February 1997 to December 2016. We defined 3 age groups: 65-79, 80-89, and 90 years and older. We included sociodemographic variables, baseline functional status, comorbidities, fracture and surgical characteristics, postoperative complications, length of stay, and in-hospital and 30-day mortality. Multiple logistic regression analysis was used to study risk factors for 30-day mortality in surgically treated nonagenarians.

RESULTS

Nonagenarians were more likely to be women and to have dementia and heart disease. Some 72% walked independently before the fracture. The most relevant treatable risk factor for 30-day mortality in nonagenarians (in terms of higher odds ratio [OR]) was developing respiratory infection (OR: 4.56, 95% confidence interval [CI]: 2.73-7.63). Better prefracture functional status (higher Katz score; OR: 0.83, 95% CI: 0.74-0.92) and spinal anesthesia (OR: 0.19, 95% CI: 0.05-0.68) decreased risk of 30-day mortality.

CONCLUSIONS

Nonagenarian patients with hip fracture differ significantly from younger patients concerning clinical characteristics, medical complications, and in-hospital and 30-day mortality rates. We identified several variables on which we could act to reduce 30-day mortality, such as respiratory infection, electrolyte disorders, polypharmacy, cardiac arrhythmia, and spinal anesthesia.

Fast-track hip and knee arthroplasty in older adults-a prospective cohort of 1,427 procedures in patients ≥85 years

INTRODUCTION

fast-track protocols in total hip and knee arthroplasty (THA/TKA) have improved postoperative recovery and reduced postoperative morbidity. Additionally, increasing life expectancy and improved surgical techniques have led to an increasing number of older adult patients undergoing THA/TKA. However, no large detailed studies on fast-track THA/TKA in older adults are available. Consequently, we aimed to describe the length of stay (LOS) and postoperative morbidity in a large cohort of patients ≥85 years within a continuous multicentre fast-track collaboration.

METHODS

we used a prospective observational cohort design with unselected consecutive data between 2010 and 2017 on primary elective THA and TKA patients ≥85 years. Data were obtained from nine centres reporting to the Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement database and the Danish National Patient Registry on LOS, readmissions and mortality. Causes of morbidity were determined by review of health records.

RESULTS

we included 1,427 (3.9% of all THA/TKA) procedures with 62.3% THA. Median age was 87 (IQR: 85-88) years with 71% women. LOS decreased from median 4 (3-6) days in 2010 to 2 (2-3) days in 2017. The proportion with LOS > 4 days decreased from 32 to 18%. Readmission and mortality rate remained at about 11.7 and 0.9% after 30 days and 16.0 and 1.5% after 90 days, respectively.

CONCLUSION

this detailed large multicentre fast-track THA/TKA study in patients ≥85 years found major reductions in LOS without increase in readmission or mortality rates. The unchanged readmission rate poses an area for further improvements.

Hypotension during hip fracture surgery and postoperative morbidity

Background

Hip fracture is a growing healthcare challenge, with 6–8% 30-day mortality and 20–30% of patients incurring major morbidity, including impaired mobilisation and ability to live independently. While observational studies have shown no benefit of general versus spinal anaesthesia on 30-day mortality, intraoperative hypotension during hip fracture surgery is associated with increased 30-day mortality regardless of anaesthetic technique. Although a recent trial on younger patients demonstrated reduced postoperative complications by maintaining intraoperative arterial blood pressure close to preoperative baseline, there are no data correlating intraoperative hypotension during hip fracture surgery with postoperative morbidity.

Objective

We evaluated the hypothesis that duration and severity of intraoperative hypotension during hip fracture surgery is associated with increased postoperative morbidity.

Methods

A retrospective analysis was carried out on n = 52 patients undergoing hip fracture surgery between January and June 2017. Measurements of patients’ intraoperative systolic arterial pressure (SAP) and mean arterial pressure (MAP) during anaesthesia, logged electronically through an anaesthesia information management system, were reviewed. We calculated the total duration of time where SAP or MAP were below pre-defined thresholds for hypotension (MAP < 75 mmHg, MAP < 55 mmHg, SAP ≤ 80% admission baseline or SAP ≤ 80% pre-induction baseline). Univariate and bivariate descriptive statistics were generated for all relevant variables. With multivariable regression models containing known predictors, cumulative duration of hypotension was correlated with postoperative comorbidities as quantified by the Clavien-Dindo and Comprehensive Complication Indices.

Results

Mean age (± SD) was 78 ± 13 years, 75% were female, 87% were ASA II or III and 60% underwent spinal anaesthesia. Mean Comprehensive Complication Index was 20.4 ± 19.2. Lowest absolute SAP and MAP values were 82 ± 18 mmHg and 55 ± 12 mmHg respectively. Cumulative time of SAP < 80% pre-induction value adjusted to gender, age and the Charlson Comorbidity Index was associated with progression to a higher Clavien-Dindo classification (odds ratio 1.020 per additional minute; 95% CI 1.008–1.035; P = 0.003).

Conclusions

In this exploratory retrospective analysis, the cumulative time of hypotension during hip fracture surgery correlated with extensive postoperative morbidity when adjusting to other known predictors. Intraoperative cumulative time of hypotension may be a good candidate for larger prediction studies as a predictor of postoperative complications. A randomised controlled trial evaluating the effect of actively minimising intraoperative hypotension on postoperative morbidity in hip fracture patients seems warranted.

UHMWPE-MWCNT-nHA based hybrid trilayer nanobiocomposite: Processing approach, physical properties, stem/bone cell functionality, and blood compatibility

The development of polymeric nanocomposites for biomedical applications remains a major challenge in terms of tailored addition of nanoparticles to realize the simultaneous enhancement of fracture resistance and cell/blood compatibility. To address this, the present work has been planned to determine whether small addition of surface functionalized multiwalled-carbon-nanotube, MWCNT (<1.5 wt%) and egg-shell derived nanosized hydroxyapatite, nHA (<10 wt%) to ultrahigh-molecular-weight-polyethylene (UHMWPE) can significantly improve the physical properties as well as biocompatibility. The difference in mouse osteoblast and human mesenchymal stem cell (hMSc) proliferation has been validated using both the monolithic composite and a trilayered composite with two different UHMWPE nanocomposites on either face with pure polymer at the middle. The combination of rheology and micro-CT with fractography reveals the homogeneous dispersion of nanofillers, leading to mechanical property enhancement. The quantitative analysis of cell viability and cell spreading by immunocytochemistry method, using vinculin and vimentin expression, establish significant cytocompatibility with hMSc and osteoblast cells onto the trilayer hybrid nanobiocomposite substrates. The hemocompatibility of the investigated composites under the controlled flow of rabbit blood in a microfluidic device reveals the signature of reduced thrombogenesis with reduction of platelet activation on UHMWPE nanocomposite w.r.t. unreinforced UHMWPE. An attempt has been made to discuss the blood compatibility results in the backdrop of the bovine serum albumin adsorption kinetics. Summarizing, the present study establishes that the twin requirement of mechanical property and cyto/hemo-compatibility can be potentially realized in developing trilayer composites in UHMWPE-nHA-MWCNT system.

Comparing Inpatient Complication Rates between Octogenarians and Nonagenarians Following Primary and Revision Total Hip Arthroplasty in a Nationally Representative Sample 2010-2014

We compared inpatient postoperative complication rates between octogenarians and nonagenarians undergoing primary and revision total hip arthroplasty (THA). We used inpatient admission data from 2010-2014 from the Nationwide Inpatient Sample (NIS). We compared the rates at which nonagenarians and octogenarians developed each complication in the inpatient setting following both primary THA (PTHA) and revision THA (RTHA). A total of 40,944 inpatient admissions were included in our study which extrapolates to a national estimate of 199,793 patients. A total of 185,799 (93%) were octogenarians and 13,994 (7%) were nonagenarians. PTHA was performed on 155,669 (78%) and RTHA was performed on 44,124 (22%) of the patients. Nonagenarians undergoing PTHA required transfusions significantly more frequently (33.13% v. 24.0%, p < 0.001) and developed urinary tract infection (5.14% v. 3.92%, p = 0.012) and acute kidney injury (5.50% v. 3.57%, p < 0.001) significantly more frequently than octogenarians. Nonagenarians undergoing RTHA required transfusions significantly more frequently (51.43% v. 41.46%, p < 0.001) and developed urinary tract infection (19.66% v. 11.73%, p < 0.001), acute kidney injury (13.8% v. 9.66%, p < 0.001), pulmonary embolism (1.24% v. 0.67%, p = 0.031), postoperative infection (1.89% v. 1.11%, p = 0.023), sepsis (3.59% v. 2.43%, p = 0.021) and other postoperative shock (1.76% v. 1.06%, p = 0.036) significantly more frequently than octogenarians. Nonagenarians undergoing RTHA also had a significantly higher inpatient mortality rate (3.28% v. 1.43%, p < 0.001) than octogenarians. Orthopedic surgeons and primary care providers can use these findings to help counsel both their octogenarian and nonagenarian patients preoperatively when considering THA. Our analysis can help these patients better understand expected inpatient complication rates and assist them in deciding whether to pursue surgical intervention when applicable.

Cardiac biomarkers improve prediction performance of the combination of American Society of Anesthesiologists physical status classification and Americal College of Surgeons National Surgical Quality Improvement Program calculator for postoperative mortality in elderly patients: a pilot study

BACKGROUND

Our previous research has shown American Society of Anaesthesiologists physical status classification (ASA) score and Americal College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator to have the most accuracy in the prediction of postoperative mortality.

AIMS

The aim of our research was to define the most reliable combination of cardiac biomarkers with ASA and ACS NSQIP.

METHODS

We have included a total of 78 patients. ASA score has been determined in standard fashion, while we used the available interactive calculator for the ACS NSQIP score. Biomarkers BIRC5, H-FABP, and hsCRP have been measured in specialized laboratories.

RESULTS

All of the deceased patients had survivin (BIRC5) > 4.00 pg/ml, higher values of H-FABP and hsCRP and higher estimated levels of ASA and ACS NSQIP (P = 0.0001). ASA and ACS NSQIP alone had AUC of, respectively, 0.669 and 0.813. The combination of ASA and ACS NSQIP had AUC = 0.841. Combination of hsCRP with the two risk scores had AUC = 0.926 (95% CI 0.853-1.000, P < 0.0001). If we add three cardiac biomarkers to this model, we get AUC as high as 0.941 (95% CI 0.876-1.000, P < 0.0001). The correction of statistical models with comorbidities (CIRS-G score) did not change the accuracy of prediction models that we have provided.

DISCUSSION

Addition of ACS NSQIP and biomarkers adds to the accuracy of ASA score, which has already been proved by other authors.

CONCLUSION

Cardiac biomarker hsCRP can be used as the most reliable cardiac biomarker; however, the "multimarker approach" adds the most to the accuracy of the combination of clinical risk scores.

Occurrence of never events after total joint arthroplasty in the United States

BACKGROUND

Total joint arthroplasty (TJA) is a major orthopedic procedure associated with substantial morbidity and mortality. Never events (NEs) are harmful hospital-acquired conditions (HACs) that are preventable.

METHODS

Information on hospital admissions with TJA was collected from the National Inpatient Sample (NIS) from 2003 to 2012. NIS was queried to identify NE applicable to TJA patients based on the HAC definition listed by the Centers for Medicare and Medicaid Services (CMS). NEs were further compared before and after 2008 to evaluate the effect of the new CMS non-reimbursement policy on their incidence.

RESULTS

A total of 8,176,774 patients were admitted with TJA from 2003 to 2012. 108,668 patients of these (1.33%) had ≥ 1 NE. The most prevalent NE was fall and trauma (0.7%). Significant multivariable predictors with higher odds of developing at least one NE included weekend admission [odds ratio (99.9% CI), 4.3 (3.1, 5.8), p < 0.001] and weight loss [odds ratio (99.9% CI), 2.8 (2.2, 3.5), p < 0.001]. A temporal comparison of NE before and after 2008 revealed a decrease in total NE occurrence after 2008 when the CMS announced discontinuing payment for NE (1.39% vs. 1.25%, p < 0.001). After adjustment for potential confounding risk factors, NE after TJA was significantly associated with an increased mortality (p < 0.001), a longer hospital stay (p < 0.001), and higher total hospitalization charges (p < 0.001).

CONCLUSIONS

These data demonstrated that NE in TJA patients was predictive of an increased mortality, length of hospital stay, and hospitalization costs. This study established baseline NE rates in the TJA patient population to use as benchmarks and identified target areas for quality improvement in US.

Nonagenarians qualify for total knee arthroplasty: a report on 329 patients from the Swedish Knee Arthroplasty Register 2000-2016

Background and purpose - The nonagenarian (those aged 90 years and older) population is expected to double in the next 20 years. This demographic age quake may have a significant impact on the incidence of total knee arthroplasty (TKA), although current literature provides limited data. We examined death and revision rates, patient-reported outcomes (PROs) and bias on patient selection of nonagenarian patients operated on with TKA for osteoarthritis (OA) between 2000 and 2016. Patients and methods - The Swedish national knee arthroplasty register was used to identify 329 nonagenarians (mean age, 92 years). Each patient was followed-up until death or the end of 2017. PRO data of 22 of these patients were compared with 65- to 74-year-old patients operated in 2015, from the same register. Results - 5 patients (1.5%) died within 90 days and 23 (7%) patients died within 365 days after TKA. 8 patients (2.4%) developed knee complications that needed revision. For patients followed for 5 and 10 years, more than 50% and 10%, respectively, lived without being revised. The patients had statistically significant improvements in PROs, not significantly different from the younger SKAR cohort. However, the material is small and this statistical finding does not preclude that there may be clinically relevant differences. TKA incidence was different amongst the 21 counties in the country (range, 0-5.1/10,000). Interpretation - Our study suggests that nonagenarians with knee OA qualify for TKA, having similar outcomes to younger patients. The data presented may help surgeons and patients assessing the risks and outcome associated with the procedure.

Age Alone Does Not Predict Complications, Length of Stay, and Cost for Patients Older Than 90 Years With Hip Fractures

The purpose of this study was to analyze the perioperative complication rate and inpatient hospitalization costs associated with hip fractures in patients older than 90 years compared with patients younger than 90 years. Patients 60 years and older with hip fractures treated operatively at 1 academic medical center between October 2014 and September 2016 were analyzed. Patient demographics, comorbidities, length of stay, procedure performed, and inpatient complications were analyzed. Total cost of admission was obtained from the hospital finance department. Outcomes were compared between patients older than 90 years and patients younger than 90 years. A total of 500 patients with hip fractures were included in this study. There were 109 (21.8%) patients 90 years and older and 391 (78.2%) patients 60 to 89 years. There was no difference in fracture pattern, operation performed, Charlson Comorbidity Index, or length of stay between the 2 groups. The mean length of stay for patients 90 years and older with hip fractures was 7.8±4.3 days vs 7.6±4.2 days for the younger cohort (P=.552). There was no observed difference in perioperative complications. Finally, there was no difference in the total mean cost of admission. Patients 90 years and older are at no greater risk for perioperative complications based on age alone. They are also no more likely to require longer or more costly hospitalizations than patients younger than 90 years. [Orthopedics. 2019; 42(1):e51-e55.].

Comparing Inpatient Complication Rates between Octogenarians and Nonagenarians following Primary and Revision Total Knee Arthroplasty in a Nationally Representative Sample, 2010⁻2014

We compared the inpatient postoperative complication rates between octogenarians and nonagenarians undergoing primary and revision total knee arthroplasty (TKA). We used the Nationwide Inpatient Sample (NIS) to analyze inpatient admission data from 2010⁻2014. We compared the rates at which nonagenarians and octogenarians developed each complication following both primary TKA (PTKA) and revision TKA (RTKA). A national estimate of 324,933 patients were included in our study. A total of 313,299 (96.42%) were octogenarians, and 11,634 (3.58%) were nonagenarians. 294,462 (90.62%) underwent PTKA, and 30,471 (9.38%) underwent RTKA. Nonagenarians undergoing PTKA had a higher inpatient mortality rate, and developed sepsis more frequently than octogenarians. Nonagenarians undergoing RTKA had a higher inpatient mortality rate, and developed cardiogenic shock more frequently than octogenarians. In both PTKA and RTKA, nonagenarians received transfusions more frequently, and developed urinary tract infection and acute kidney injury more frequently than octogenarians. In both PTKA and RTKA, nonagenarians sustained a higher inpatient mortality rate than octogenarians. Orthopedic surgeons should counsel nonagenarian patients undergoing both PTKA and RTKA preoperatively about this increased mortality risk, as well as the increased risks of more minor complications like transfusion, urinary tract infection, and acute kidney injury.

The impact of older age on patient outcomes following primary total knee arthroplasty

Aims

As the population ages, there is projected to be an increase in the level of demand for total knee arthroplasty (TKA) in octogenarians. We aimed to explore whether those aged ≥ 80 years achieved similar improvements in physical function to younger patients while also comparing the rates of length of stay (LOS), discharge to rehabilitation, postoperative complications, and mortality following TKA in older and younger patients.

Patients and Methods

Patients from one institution who underwent primary elective TKA between 1 January 2006 and 31 December 2014 were dichotomized into those ≥ 80 years old (n = 359) and those < 80 years old (n = 2479) for comparison. Multivariable regression was used to compare the physical status component of the 12-Item Short-Form Health Survey (SF-12), LOS, discharge to rehabilitation, complications, and mortality between the two groups.

Results

Both age groups demonstrated a clinically meaningful improvement in their self-reported physical health relative to their baseline with no clinically relevant difference noted between them. Being ≥ 80 years old was associated with a 0.58-day increase in LOS and older patients were more likely to be discharged to rehabilitation (odds ratio (OR) 3.06, p < 0.001). Medical complications and mortality were higher in elderly patients (OR 1.92 for complications, p < 0.001; hazard ratio 3.40 for death, p < 0.001). There was no statistically significant association between age group and experiencing a postoperative surgical or wound-related complication.

Conclusion

Those aged over 80 years achieved a statistically significant lower median SF-12 physical score than the younger group, after adjusting for the preoperative score, but this difference of 4.46 was not considered to be clinically meaningful. However, clinicians should be aware that the elderly are at a higher risk of experiencing longer hospital stays, postoperative medical complications, and mortality. Cite this article: Bone Joint J 2018;100-B:1463–70.

Perioperative Complication Rates in Pediatric Total Joint Arthroplasty Patients Compared With Adults: Results of a Matched Cohort Study

BACKGROUND

One of the least studied areas in orthopaedics is total joint arthroplasty (TJA) in pediatric patients. Recent studies have confirmed that these procedures are being performed on pediatric patients, making it critical to understand the rates of surgical complications in this patient population. We sought to examine the frequency in which surgical complications occur in pediatric patients, aged 20 and younger, undergoing TJA compared with adults.

METHODS

Data from the 2003 to 2012 Kids' Inpatient Database (ages 20 and younger) and 2002 to 2013 National Inpatient Sample (ages 21 and over) were analyzed. Pediatric patients were matched to 3 adult controls (1 per age group: 21 to 50, 51 to 65, and over 65 y) using patient characteristics including sex, race, orthopaedic diagnosis, and preoperative loss of function. Comparisons were then made between the rates and relative risks (RRs) of surgical complications between pediatric and adult patients. Finally, we examined patient factors associated with surgical complications, utilizing modified Poisson regression models with robust SEs.

RESULTS

Three adult controls (ie, 1 control from each age group) were identified for 1385 pediatric patients, for a total sample of 5540 TJA patients. Approximately 10% of pediatric patients experienced either major or minor surgical complications. The overall rate of major complications in pediatric patients was 5.05%, compared with 4.79% in adult controls [RR: 1.06 (0.81 to 1.38), P=0.69]. The overall rate of minor complications in pediatric patients was 5.78%, compared with 5.68% in adult controls [RR: 1.02 (0.80 to 1.30), P=0.78]. When adjusted for patient demographics, the RR of major complications was 49% higher in pediatric patients compared with ages 21 to 50 [RR: 1.49 (1.03 to 2.16), P=0.03] with no statistically significant differences noted for other age groups. For minor complications, the adjusted RR in pediatric patients, compared with any other age group, did not approach statistical significance.

CONCLUSIONS

Pediatric patients undergoing TJA experience major and minor surgical complications at rates comparable with their adult counterparts. Our findings offer important insight on the rates of surgical complications in pediatric TJA patients, which is valuable for preoperative education and consultation with patients and families.

LEVEL OF EVIDENCE

Level III-therapeutic.

Complications and Mortality Following Total Hip Arthroplasty in the Octogenarians: An Analysis of a National Database

BACKGROUND

As advances in medicine have increased life expectancy, more octogenarians are undergoing total hip arthroplasty (THA) than ever before. Concerns exist, however, about the safety of performing this elective procedure in this age group. The purpose of this study is to determine the 30-day complications associated with THA patients over 80 years of age and to identify high-risk patients.

METHODS

We queried the American College of Surgeons-National Surgical Quality Improvement Program database for all patients who underwent primary THA from 2011 to 2014. Demographic variables, medical comorbidities, and 30-day complication, readmission, and reoperation rates were compared between patients under vs over 80 years of age. A multivariate logistic regression analysis was then performed to identify independent risk factors of poor short-term outcomes.

RESULTS

Of the total 66,839 patients who underwent THA, 7198 (11%) patients were 80 years of age or older. Octogenarians had a higher overall complication rate (29% vs 15%, P < .001) and a higher mortality rate (0.9% vs 0.1%, P < .001). When controlling for other comorbidities, age over 80 years is an independent risk factor for mortality (odds ratio 2.02, 95% confidence interval 1.25-3.26, P = .004) and complications (odds ratio 1.41, 95% confidence interval 1.30-1.525, P < .001) following THA. Malnutrition and chronic kidney disease are also independent risk factors for readmission, complications, and mortality (all P < .05).

CONCLUSION

THA in patients older than 80 years old are at an increased risk of complications and mortality. Octogenarian patients should be counseled on their risk profile, particularly those with malnutrition and chronic kidney disease.

Thirty-day Postoperative Complications following Primary Total Knee Arthroplasty: A Retrospective Study of Incidence and Risk Factors at a Single Center in China

BACKGROUND

Total knee arthroplasty (TKA) may be associated with serious complications that adversely affect outcomes and increase the likelihood of disability. However, few studies with sufficient sample size have reported postoperative complications following TKA among Chinese patients. This study aimed to evaluate complications of TKA within 30 postoperative days and to identify the related risk factors.

METHODS

A retrospective complication-based analysis of TKA using the arthroplasty registry between 2008 and 2013 was performed by summarizing complications of TKA within 30 postoperative days. Multivariate logistic regression was used to identify the predicting factors for complications 30 days after operation.

RESULTS

A total of 1542 patients underwent 2254 primary TKA between January 2008 and December 2013. A total of 137 complications occurred within 30 days after operation with an incidence rate of 6.1%. The incidence rate of major systemic complications within postoperative 30 days was 2.3%, with cardiovascular and respiratory complications as the most common complications. The incidence rates of deep venous thrombosis (DVT) and local complications were 2.4% and 1.0%, respectively. The 30-day postoperative mortality rate was 0.1% (3/2254). Multivariate logistic regression analyses identified body mass index (BMI) of ≥30.0 kg/m2 (odds ratio [OR]: 1.47) and age ≥80 years (OR: 1.87) as significant risk factors for postoperative systemic complications. A BMI of ≥30.0 kg/m2 was a significant risk factor for DVT (OR: 2.86) and other complications (OR: 2.11). The comorbidity of diabetes was a risk factor for postoperative mortality (OR: 19.20).

CONCLUSIONS

This study highlighted complications with cardiac and respiratory origins as the most common complications within 30 postoperative days following primary TKA. The BMI of ≥30.0 kg/m2 and age ≥80 years were significant risk factors for 30-day postoperative complications.

Addition of biomarker panel improves prediction performance of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator for cardiac risk assessment of elderly patients preparing for major non-cardiac surgery: a pilot study

BACKGROUND

Number of elderly patients subjected to extensive surgical procedures in the presence of cardiovascular morbidities is increasing every year. Therefore, there is a need to make preoperative diagnostics more accurate.

AIMS

To evaluate the usefulness of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator as a predictive tool in preoperative assessment of cardiovascular risk in elderly patients.

METHODS

This prospective pilot study included 78 patients who were being prepared for extensive non-cardiac surgeries under general anaesthesia. Their data have been processed on the interactive ACS NSQIP calculator. Blood sampling has been performed 7 days prior to surgery, and serum has been separated. Clinical, novel, and experimental biomarkers [hsCRP, H-FABP, and Survivin (BIRC5)] have been measured in specialized laboratories.

RESULTS

Mean age of included patients was 71.35 ± 6.89 years. In the case of heart complications and mortality prediction, hsCRP and ACS NSQIP showed the highest specificity and sensitivity with AUC, respectively, 0.869 and 0.813 for heart complications and 0.883 and 0.813 for mortality. When combined with individual biomarkers AUC of ACS NSQIP raised, but if we combined all three biomarkers with ACS NSQIP, AUC reached as much as 0.920 for heart complications and 0.939 for mortality.

DISCUSSION

ACS NSQIP proved to reduce inaccuracy in preoperative assessment, but it cannot be used independently, which has already been proved by other authors.

CONCLUSIONS

Our results indicate that ACS NSQIP represents an accurate tool for preoperative assessment of elderly patients, especially if combined with cardiac biomarkers.

Clinical Utility of Survivin (BIRC5), Novel Cardiac Biomarker, as a Prognostic Tool Compared to High-sensitivity C-reactive Protein, Heart-type Fatty Acid Binding Protein and Revised Lee Score in Elderly Patients Scheduled for Major Non-cardiac Surgery: A Prospective Pilot Study

BACKGROUND

Recent studies indicate that survivin (BIRC5) is sensitive to the existence of previous ischemic heart disease, since it is activated in the process of tissue repair and angiogenesis. The aim of this study was to determine the potential of survivin (BIRC5) as a new cardiac biomarker in the preoperative assessment of cardiovascular risk in comparison with clinically accepted cardiac biomarkers and one of the relevant clinical risk scores.

METHODS

We included 79 patients, female (41) and male (38), with the mean age of 71.35±6.89. Inclusion criteria: extensive non-cardiac surgery, general anesthesia, age >55 and at least one of the selected cardiovascular risk factors (hypertension, diabetes mellitus, hyperlipidemia, smoking and positive family history). Exclusion criteria: emergency surgical procedures and inability to understand and sign an informed consent. Blood sampling was performed 7 days prior surgery and levels of survivin (BIRC5), hsCRP and H-FABP were measured.

RESULTS

Revised Lee score was assessed based on data found in patients' history. Levels of survivin (BIRC5) were higher in deceased patients (P<0.05). It showed AUC=0.807 (95% CI, P<0.0005, 0.698-0.917), greater than both H-FABP and revised Lee index, and it increases the mortality prediction when used together with both biomarkers and revised Lee score. The determined cut-off value was 4 pg/mL and 92.86% of deceased patients had an increased level of survivin (BIRC5), (P=0.005).

CONCLUSIONS

Survivin (BIRC5) is a potential cardiac biomarker even in elderly patients without tumor, but it cannot be used independently. Further studies with a greater number of patients are needed.

What Is the Impact of Advancing Age on the Outcomes of Total Hip Arthroplasty?

BACKGROUND

The global demand for total hip arthroplasty (THA) is increasing, underscoring its moniker as the "operation of the century." However, debate still exists as to whether the elderly who undergo the operation achieve the same outcomes as those younger. In this study, we sought to investigate the association between older age and the risks and benefits of THA.

METHODS

In this study, we aimed to compare the risks and benefits of THA of those aged ≥80 years vs those <80 years. We analyzed the physical status component of the Short-Form 12 Health Survey, complications within 12 months, all-cause mortality, length of hospital stay (LOS), and discharge to rehabilitation in 2457 cases of primary THA using multivariate modeling.

RESULTS

There was no difference in improvement of those older vs the younger group in physical functioning. However, the older group had 2.87 times greater odds of experiencing a post-operative medical complication and 3.49 times the rate of all-cause mortality (P < .001). Additionally, the older group encountered an additional median 0.21-day increase in LOS and had 3.93 times greater odds of being discharged to rehabilitation rather than home (P < .001). We were unable to demonstrate any difference between groups in terms of post-operative surgical or wound-related complications.

CONCLUSION

The elderly stand to gain equivalent benefits from THA as those younger in terms of physical functioning. However, this benefit needs to be balanced against the increased risk of post-operative medical complications, increased LOS, increased requirement for rehabilitation, and ultimately the increased risk of mortality.

Augmentation of musculoskeletal regeneration: role for pluripotent stem cells

The rise in the incidence of musculoskeletal diseases is attributed to an increasing ageing population. The debilitating effects of musculoskeletal diseases, coupled with a lack of effective therapies, contribute to huge financial strains on healthcare systems. The focus of regenerative medicine has shifted to pluripotent stem cells (PSCs), namely, human embryonic stem cells and human-induced PSCs, due to the limited success of adult stem cell-based interventions. PSCs constitute a valuable cell source for musculoskeletal regeneration due to their capacity for unlimited self-renewal, ability to differentiate into all cell lineages of the three germ layers and perceived immunoprivileged characteristics. This review summarizes methods for chondrogenic, osteogenic, myogenic and adipogenic differentiation of PSCs and their potential for therapeutic applications.

Discriminative Ability of Elixhauser's Comorbidity Measure is Superior to Other Comorbidity Scores for Inpatient Adverse Outcomes After Total Hip Arthroplasty

BACKGROUND

Identifying patients at highest risk for a complex perioperative course following total hip arthroplasty (THA) is more important than ever in order to educate patients, optimize outcomes, and to minimize cost and length of stay. There are no known studies comparing the clinically relevant discriminative ability of 3 commonly used comorbidity indices for adverse outcomes following THA: Elixhauser Comorbidity Measure (ECM), the Charlson Comorbidity Index (CCI), and the modified Frailty Index (mFI).

METHODS

Patients undergoing THA were extracted from the 2013 National Inpatient Sample. The discriminative ability of ECM, CCI, and mFI, as well as the demographic factors age, body mass index, and gender for the occurrence of index admission Centers for Medicare & Medicaid Services procedure-specific complication measures, extended length of hospital stay, and discharge to a facility were assessed using the area under the curve analysis from receiver operating characteristic curves.

RESULTS

ECM outperformed CCI and mFI for the occurrence of all 5 adverse outcomes. Age outperformed gender and obesity for the occurrence of all 5 adverse outcomes. ECM (the best performing comorbidity index) outperformed age (the best performing demographic factor) in discriminative ability for the occurrence of 3 of 5 adverse outcomes.

CONCLUSION

The less commonly used ECM outperformed the more often utilized CCI and newer mFI as well as demographic factors in correctly preoperatively identifying patients' probabilities of experiencing an adverse outcome suggesting that wider adoption of ECM should be considered in both identifying likelihoods of adverse patient outcomes and for research purposes in future studies.

Comorbidities Have a Greater Impact Than Age Alone in the Outcomes of Octogenarian Total Knee Arthroplasty

BACKGROUND

Increasing age and various comorbidities are known risk factors for complications after total knee arthroplasty (TKA), but data on the impact of total comorbidity burden is scarce. We investigated the effect of age and total comorbidity burden on outcomes after primary TKA in octogenarians (OGs).

METHODS

A matched-pair comparison study was conducted using prospectively collected TKA registry data in a large tertiary institution. Between 2006 and 2011, consecutive OGs undergoing primary unilateral TKA, with minimum 2-year follow-up, were matched 1:1 with younger controls based on demographic and surgical variables. We compared the Charlson comorbidity index (CCI), complication rate, length of stay (LOS), 30-day readmission, and 2-year reoperation rate. Multivariate analysis was performed to determine the effects of age and CCI on each outcome.

RESULTS

There were 209 OGs and 209 controls. OGs were significantly older (mean age 82.1 vs 66.1 years, P < .001) and had higher CCI. OGs had longer mean LOS (6.3 vs 5.4 days, P = .001), and a trend for more complications and readmissions. The complication rate increased from 7.5% for CCI = 0, to 33.3% for CCI ≥3 (P = .005). The LOS increased from 5.4 days for CCI = 0, to 9.6 days for CCI ≥3 (P < .001). Multivariate analysis showed that higher CCI was an independent risk factor for complications and longer LOS, whereas age was not.

CONCLUSION

Comorbidity burden has a greater impact than age alone on TKA outcomes in OGs. Well-selected OGs remain good candidates for TKA.

Risk-Benefit on Quality of Life After Total Knee Arthroplasty in Octogenarians

BACKGROUND

Clinical outcomes of total knee arthroplasty (TKA) in very older patients have been widely studied, but the available evidence on quality of life (QOL) is limited. The objective was to evaluate the impact of TKA on the QOL in octogenarian patients and assess whether the risk-benefit justified surgery.

METHODS

Prospective study comparing 143 octogenarian and 149 septuagenarian patients. QOL was assessed with the Short Form-12 (SF-12) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaires and functional outcomes with the Knee Society score (KSS). Comorbidity, complications, pain, and satisfaction were also assessed.

RESULTS

Mean postoperative follow-up was 3.2 years (range, 2-5 years). Comorbidities, medical complications, transfusion rate, and length stay were not different between groups (P < .05). Comorbidities and complications had no influence on the outcomes. There were no significant differences in preoperative knee KSS, WOMAC, or SF-12 mental scores, but octogenarians had significantly lower functional KSS (P = .003) and SF-12 physical scores (P = .005). At the last follow-up, there were no significant differences in KSS, WOMAC, and SF-12 physical scores (P < .05), but octogenarians had higher SF-12 mental (P = .030) and satisfaction (P = .031) scores.

CONCLUSION

TKA provided pain relief, satisfaction, and improvement in QOL for octogenarian patients to the level of the septuagenarian patients. TKA was a suitable option for octogenarian patients with appropriate surgical indications and manageable risk.

Postoperative Morbidity and Discharge Destinations After Fast-Track Hip and Knee Arthroplasty in Patients Older Than 85 Years

BACKGROUND

Elderly patients are at risk of increased length of hospital stay (LOS), postoperative complications, readmission, and discharge to destinations other than home after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). Recent studies have found that enhanced recovery protocols or fast-track surgery can be safe for elderly patients undergoing these procedures and may result in reduced LOS. However, detailed studies on preoperative comorbidity and differentiation between medical and surgical postoperative morbidity in elderly patients are scarce. The aim of this study was to provide detailed information on postoperative morbidity resulting in LOS >4 days or readmissions <90 days after fast-track THA and TKA in patients ≥85 years.

METHODS

This is a descriptive, observational study in consecutive unselected patients ≥85 years undergoing fast-track THA/TKA. The primary outcome was the causes of postoperative morbidity leading to an LOS of >4 days. Secondary outcomes were 90-day surgically related readmissions, discharge destination, 90-day mortality, and role of disposing factors for LOS >4 days and 90-day readmissions. Data on preoperative characteristics were prospectively gathered using patient-reported questionnaires. Data on all admissions were collected using the Danish National Health Registry, ensuring complete follow-up. Any cases of LOS >4 days or readmissions were investigated through review of discharge forms or medical records. Backward stepwise logistic regression was used for analysis of association between disposing factors and LOS >4 days and 90-day readmission.

RESULTS

Of 13,775 procedures, 549 were performed in 522 patients ≥85 years. Median age was 87 years (interquartile range, 85-88) and median LOS of 3 days (interquartile range, 2-5). In 27.3% procedures, LOS was >4 days, with 82.7% due to medical causes, most often related to anemia requiring blood transfusion and mobilization issues. Use of walking aids was associated with LOS >4 days (odds ratio [OR], 1.99; 95% confidence interval [CI], 1.26-3.15; P = 0.003), whereas preoperative anemia showed borderline significance (OR, 1.52; 95% CI, 0.99-2.32; P = 0.057). Thirty-eight patients (6.9%) were not discharged directly home, of which 68.4% had LOS >4 days. Readmission rates were 14.2% and 17.9% within 30 and 90 days, respectively, and 75.5% of readmissions within 90 days were medical, mainly due to falls and suspected but disproved venous thromboembolic events. Preoperative anemia was associated with increased (OR, 1.81; 95% CI, 1.13-2.91; P = 0.014) and living alone with decreased (OR, 0.50; 95% CI, 0.31-0.80; P = 0.004) risk of 90-day readmissions. Ninety-day mortality was 2.0%, with 1.0% occurring during primary admission.

CONCLUSIONS

Fast-track THA and TKA with an LOS of median 3 days and discharge to home are feasible in most patients ≥85 years. However, further attention to pre- and postoperative anemia and the pathogenesis of medical complications is needed to improve postoperative outcomes and reduce readmissions.

The Impact of Solid Organ Transplant History on Inpatient Complications, Mortality, Length of Stay, and Cost for Primary Total Hip Arthroplasty Admissions in the United States

BACKGROUND

As the prevalence of and life expectancy after solid organ transplantation increases, some of these patients will require total hip arthroplasty (THA). Immunosuppressive therapy, metabolic disorders, and post-transplant medications may place transplant patients at higher risk of adverse events following surgery. The objective of this study was to compare inpatient complications, mortality, length of stay (LOS), and costs for THA patients with and without solid organ transplant history.

METHODS

A retrospective cross-sectional analysis was conducted using 1998-2011 Nationwide Inpatient Sample. Primary THA patients were queried (n = 3,175,456). After exclusions, remaining patients were assigned to transplant (n = 7558) or non-transplant groups (n = 2,772,943). After propensity score matching, adjusted for patient and hospital characteristics, logistic regression and paired t-tests examined the effect of transplant history on outcomes.

RESULTS

Between 1998 and 2011, THA volume among transplant patients grew approximately 48%. The overall prevalence of one or more complications following THA was greater in the transplant group than in the non-transplant group (32.0% vs 22.1%; P < .001). In-hospital mortality was minimal, with comparable rates (0.1%) in both groups (P = .93). Unadjusted trends show that transplant patients have greater annual and overall mean LOS (4.47 days) and mean admission costs ($18,402) than non-transplant patients (3.73 days; $16,899; P < .001). After propensity score matching, transplant history was associated with increased complication risk (odds ratio, 1.56) after THA, longer hospital LOS (+0.64 days; P < .001), and increased admission costs (+$887; P = .005).

CONCLUSION

Transplant patients exhibited increased odds of inpatient complications, longer LOS, and greater admission costs after THA compared with non-transplant patients.

Does Marital Status Impact Outcomes After Total Knee Arthroplasty?

BACKGROUND

There is a paucity of research on the relationship between marital status and patient outcomes following total knee arthroplasty (TKA).

METHODS

This was a retrospective chart review of patients who underwent TKA by a single surgeon at a university-based orthopedic practice. Data abstracted included age, gender, marital status, body mass index, length of hospital stay, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Oxford Knee Score (OKS). The WOMAC and OKS were administered at the preoperative visit and at approximately 10, 30, 90, and 180 days after TKA. Multivariate analyses with patient-reported outcomes as repeated measures, marital status, day of assessment; and the interaction of marital status and day of assessment as fixed effects; and age, gender, body mass index, and length of hospital stay as covariates were conducted as well as analyses in which preoperative patient-reported outcomes were treated as fixed effects.

RESULTS

Of 422 patients who underwent TKA during the study period, complete data were available for 249, of whom 124 were married and 125 unmarried. Married patients had significantly higher WOMAC scores than unmarried patients at all postoperative assessments, even after controlling for preoperative scores. Although married patients also had significantly higher postoperative OKS scores than their unmarried peers, differences between groups were attenuated after adjusting for preoperative OKS scores.

CONCLUSION

This study found that married patients have better overall outcomes after TKA but yielded conflicting results as to whether the positive effects of marriage are specific to the postoperative period.

Total Hip and Knee Arthroplasty in Patients Older Than Age 80 Years

A rapidly aging population is currently reshaping the demographic profile of the United States. Among older patients, the cohort aged >80 years is not only living longer but also is electing to undergo more total hip and knee arthroplasties. To improve perioperative safety, orthopaedic surgeons should understand the risks and clinical outcomes of arthroplasty in patients of advanced age. Although morbidity and mortality rates are higher for patients aged >80 years than for younger patients undergoing total hip and knee arthroplasties and revision surgeries, functional outcomes, pain relief, and patient satisfaction are consistent between groups. In addition, geriatric co-management before total hip and total knee arthroplasty has reduced the rate of minor complications and the length of hospital stays in elderly patients. Surgeons should inform older patients and their families of the increased risks of morbidity and mortality before these procedures are undertaken.

[Perioperative risk and mortality after major surgery]

Although anesthesia-associated mortality has been significantly reduced down to 0.00068-0.00082% over the last decades, recent studies have revealed a high perioperative mortality of 0.8- 4%. Apart from anesthesia and surgery-induced major complications, perioperative mortality is primarily negatively influenced by individual patient comorbidities. These risk factors predispose for acute critical incidents (e.g., myocardial infarction); however, the majority of fatal complications are a result of slowly progressing conditions, particularly infections or the sequelae of systemic inflammation. This implicates a broad window of opportunity for the detection and treatment of slow-onset complications to improve the perioperative outcome. The term "failure to rescue" (FTR), i.e., the proportion of patients who die from major complications compared to the number of all patients with complications, has been introduced as a valid indicator for the quality of perioperative care. Growing evidence has already shown that FTR is an underestimated factor in perioperative medicine accounting for or at least being involved in the development of postoperative mortality. While the incidence of severe postoperative complications amazingly does not show much variation between hospitals, FTR shows significant differences implying a major potential for improvement. With 14 million surgical procedures per year in Germany, a postoperative mortality of approximately 1% and an avoidable FTR rate of 40% mean that there are an estimated 60,000 preventable deaths per year. Hence, in the future it will be imperative to (1) identify patients at risk, (2) to prevent the development of postoperative complications with the use of adequate adjunctive therapeutic strategies, (3) to establish surveillance and monitoring systems for the early detection of postoperative complications and (4) to treat postoperative complications efficiently and in time when they arise.

Prediction of Mortality in Nonagenarians Following the Surgical Repair of Hip Fractures

BACKGROUND

The purpose of this study is to report on the mortality of nonagenarians who underwent surgical treatment for a hip fracture, specifically in regards to preexisting comorbidities. Furthermore, we assessed the effectiveness of the Deyo score in predicting such mortality.

METHODS

Thirty-nine patients over the age of 90 who underwent surgical repair of a hip fracture were retrospectively analyzed. Twenty-six patients (66.7%) suffered femoral neck fractures, while the remaining 13 (33.3%) presented with trochanteric type fractures. Patient charts were examined to determine previously diagnosed patient comorbidities as well as living arrangements and mobility before and after surgery.

RESULTS

Deyo index scores did not demonstrate statistically significant correlations with postoperative mortality or functional outcomes. The hazard of in-hospital mortality was found to be 91% (p = 0.036) and 86% (p = 0.05) less in patients without a history of congestive heart failure (CHF) and chronic pulmonary disease (CPD), respectively. Additionally, the hazard of 90-day mortality was 88% (p = 0.01) and 81% (p = 0.024) less in patients without a history of dementia and CPD, respectively. The hazard of 1-year mortality was also found to be 75% (p = 0.01) and 80% (p = 0.01) less in patients without a history of dementia and CPD, respectively. Furthermore, dementia patients stayed in-hospital postoperatively an average of 5.3 days (p = 0.013) less than nondementia patients and only 38.5% returned to preoperative living conditions (p = 0.036).

CONCLUSIONS

Nonagenarians with a history of CHF and CPD have a higher risk of in-hospital mortality following the operative repair of hip fractures. CPD and dementia patients over 90 years old have higher 90-day and 1-year mortality hazards postoperatively. Dementia patients are also discharged more quickly than nondementia patients.