By 2030, patients aged 85 and older are projected to account for 2.3% of the United States population, but this figure is expected to nearly double by 2050. There has also been an increasing trend in surgery being performed in the very elderly, but these patients have multiple risk factors that may increase their risk for adverse outcomes after surgery. As a result, there has been some controversy around performing elective surgeries to enhance quality of life (QOL) in this patient population.
Typically, major orthopedic procedures like spinal fusion, total hip arthroplasty (THA), and total knee arthroplasty (TKA) are performed electively to alleviate pain and improve QOL. In a study published in the Journal of Bone & Joint Surgery, Hiroyuki Yoshihara, MD, PhD, and colleagues examined the trends and in-hospital outcomes of elective major orthopedic surgeries in patients who were at least 80 years old from 2000 to 2009 using data from the National Inpatient Sample on patients who underwent spinal fusion, THA, and TKA. The analysis included more than 70,000 spinal fusion cases, 233,000 THAs, and 417,000 TKAs. Complication and mortality rates were also compared for patients aged 80 and older with those aged 65 to 79.
Incidence, Complications, & Mortality
According to the study, there was an increasing trend in the age-adjusted incidence of spinal fusion, THA, and TKA in patients at least 80 years of age from 2000 to 2009. The age-adjusted incidence of spinal fusion increased from 40 to 101 per 100,000 people per year. For THA, the incidence increased from 181 to 257 per 100,000 people. For TKA, the incidence rose from 300 to 477 per 100,000 people. The duration of hospital stay of patients aged 80 and older decreased over time for each of the elective procedures.
During the study period, the overall in-hospital complication rates remained stable for spinal fusion and TKA but increased for THA (Figure 1). The in-hospital complication rate was 17.5% in 2000 and 16.1% in 2009 for spinal fusion. For THA, corresponding rates were 9.9% in 2000 and 9.1% in 2009. For TKA, the in-hospital complication rate increased from 9.0% to 10.3%. The study group noted that the complication rate increased with the number of comorbidities for each of the procedures. They recommended that these elective procedures be reserved for very elderly patients with few or no comorbidities.
Dr. Yoshihara and colleagues also found that the in-hospital mortality rate decreased for all three procedures for the duration of the study (Figure 2). For spine fusion, the mortality rate dropped from 1.1% to 0.6% from 2000 to 2009. For THA, rates decreased from 0.5% to 0.3%, and for TKA, these rates dropped from 0.3% to 0.2%. These findings may reflect improvements in the care of complications over the previous decade.
Comparing Age Groups
When the study compared patients aged 80 and older with those between the ages of 65 and 79, the authors found that the overall in-hospital complication and mortality rates of the older group were higher than in their younger counterparts. In-hospital complication rates after spinal fusion were 16.3% for patients aged 80 and older, compared with 12.5% for those aged 65 to 79. For THA, in-hospital complication rates were 9.9% for older participants and 7.0% for younger participants. For TKA, the corresponding rates were 8.9% and 6.9% for older and younger patients, respectively. In-hospital mortality rates were 0.9% for the older group, compared with 0.3% for younger patients after spinal fusion. Corresponding rates were 0.5% versus 0.1% after THA and 0.3% versus 0.1% after TKA.
“Although the overall in-hospital complication and mortality rates were higher for octogenarians for all three procedures, the differences we observed were small,” says Dr. Yoshihara. When a large sample is analyzed like the one used in the study, Dr. Yoshihara says it is likely that small differences will be detected using statistical tests. He also noted that the study included data from surgeons of all experience levels, not just from experienced surgeons.
Consulting With Patients
In light of the findings, Dr. Yoshihara says it is reasonable to consider these orthopedic procedures in patients aged 80 and older, but the potential risks should be acknowledged. “Some older patients will be healthier than others or have fewer comorbidities,” he says. “These elective procedures can be offered to very elderly patients as long as they accept the slightly higher risks, but we should still keep the patient’s overall health in mind.” Very elderly patients who have not improved with more conservative treatments—especially those with few or no comorbidities—may benefit from these elective surgeries.
Readings & Resources (click to view)
Yoshihara H, Yoneoka D. Trends in the incidence and in-hospital outcomes of elective major orthopaedic surgery in patients eighty years of age and older in the United States from 2000 to 2009. J Bone Joint Surg Am. 2014;96:1185-1191. Available at: http://jbjs.org/content/96/14/1185.
Yoshihara H, Yoneoka D. Understanding the statistics and limitations of large database analyses. Spine (Phila Pa 1976). 2014;39:1311-1312.
Kreder HJ, Berry GK, McMurtry IA, Halman SI. Arthroplasty in the octogenarian: quantifying the risks. J Arthroplasty. 2005;20:289-293.
Smith HE, Kerr SM, Maltenfort M, et al. Early complications of surgical versus conservative treatment of isolated type II odontoid fractures in octogenarians: a retrospective cohort study. J Spinal Disord Tech. 2008;21:535-539.
Singh JA, Vessely MB, Harmsen WS, et al. A population-based study of trends in the use of total hip and total knee arthroplasty, 1969-2008. Mayo Clin Proc. 2010;85:898-904.
Liu SS, Della Valle AG, Besculides MC, Gaber LK, Memtsoudis SG. Trends in mortality, complications, and demographics for primary hip arthroplasty in the United States. Int Orthop. 2009;33:643-651.
Memtsoudis SG, Della Valle AG, Besculides MC, Gaber L, Laskin R. Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty. J Arthroplasty. 2009;24:518-527.