The Journal of Arthroplasty 30 (2015) 407–410
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Primary Collared Uncemented Total Hip Arthroplasties in the Elderly: A Safe and Reliable Treatment Option Gavin Schaller, MBBS, BSc(Hons), MRCS a, Jonathon Black, MBBS, MSc, MRCS a, Asaad Asaad, MD, MSc, MRCS a, Nick Harper, MBBS, FRCA, FFICM a, Stuart Webb, BSc, MD, FRCP b, Sarah Muirhead-Allwood, BSc(Hons), MBBS, FRCS a a b
The London Hip Unit, London, England King Edward VII's Hospital Sister Agnes, London, England
a r t i c l e
i n f o
Article history: Received 6 August 2014 Accepted 5 October 2014 Keywords: primary total hip arthroplasty uncemented total hip arthroplasty octogenarian nonagenarian collared femoral prosthesis
a b s t r a c t The age of patients undergoing primary Total Hip Arthroplasty (THA) remains fairly constant despite an increasingly elderly population, possibly owing to concern over postoperative complications. This study evaluated 90-day outcomes in patients over 80, undergoing uncemented collared primary THA for osteoarthritis in a high volume unit. Data were recorded from 153 consecutive patients. There were 0.65% mortality rate and 1.3% major systemic complication rate. American Society of Anesthesiologist (ASA) grade was an independent predictor of inpatient complications. Mean preoperative and 90-day postoperative Oxford Hip Score was 24 and 46 respectively. No radiological evidence of femoral stem migration was seen. Our cohort shows low morbidity and mortality rates. ASA not age helps predict inpatient complications. Uncemented collared femoral prosthesis resulted in excellent functional and radiological outcomes. © 2014 Elsevier Inc. All rights reserved.
Within Western Society there continues to be an increase in the population of octogenerians and nonagenarians, with those over the age of 85 years the fastest growing group in England and Wales [1]. The number of primary Total Hip Arthroplasties (THAs) has been steadily increasing over the past few decades internationally [2–5]. Those over 85 years of age are as willing as younger cohorts to undergo surgery and gain as much function and pain relief following surgery [6]. Despite this however, studies have found the mean age of patients undergoing THA to be fairly constant or even falling [2,3]. This may reflect a hesitancy to perform major elective surgery on older patients out of concern of co-morbidities and of higher rates of post-operative complications [6–8]. Uncemented femoral prosthesis can undergo complications within the short term with regards to subsidence of the femoral stem, loosening with fibrous ingrowth at the bone–implant interface and a risk of periprosthetic fracture before bony ingrowth has occurred [9,10]. Theoretically this risk is increased within the elderly population who have decreased bone density and bone strength and therefore have a greater risk of bony expansion around the femoral prosthesis [11]. Within this cohort (N80 years of age), a collared uncemented femoral component is routinely used at our unit to mitigate these short term risks and allow for early mobilisation [12].
The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2014.10.004. Reprint requests: Gavin Schaller, MBBS, BSc(Hons), MRCS, The London Hip Unit, 30 Devonshire St, London, England, W1G 6PU. http://dx.doi.org/10.1016/j.arth.2014.10.004 0883-5403/© 2014 Elsevier Inc. All rights reserved.
The objective for this study was to evaluate the 90-day complication rate in the elderly population undergoing uncemented collared primary THA for osteoarthritis within our single surgeon unit. Materials and Methods Over a period of 60 months, data from a consecutive cohort of patients over the age of 80 years and operated on by a single surgeon were recorded. Only primary THAs done for osteoarthritis were included in the study. After being preoperatively accessed by both a Consultant Physician and Consultant Anaesthetist, all patients were operated on by a single, high volume Consultant Hip Surgeon (SMA) using a mini posterior approach. The THA was carried out under general anaesthesia or spinal epidural. Uncemented collared femoral components were used in all patients. Two types of collared prosthesis were used (Corail, Depuy and Profemur Gladiator, Wright Medical). The choice of femoral prosthesis was determined during preoperative planning based upon patient anatomy with the Profemur Gladiator stem chosen for short femoral necks on templating. All acetabular cups were uncemented. Patients had a drain placed that was removed 24 h postoperatively. Thromboprophylaxis was administered with TED stockings, intermittent compression device and enoxaparin given daily as an inpatient. Antibiotics were given on induction and 2 doses postoperatively. Postoperative bloods and check radiograph were taken on the first day after surgery and all patients were mobilised either on the day of surgery or day 1 postoperatively fully weight bearing. On discharge prior to June 2009 all patients were discharged with a daily dose of 75 mg aspirin for
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G. Schaller et al. / The Journal of Arthroplasty 30 (2015) 407–410
4 weeks. Our protocol changed after this date, with patients’ discharged to take Rivaroxaban for 4 weeks. Patient demographic data together with the preoperative American Society of Anesthesiologist (ASA) grade were recorded. The inpatient length of stay and complications over the first 90 days were recorded along with any readmissions within this time period. Antero-posterior radiographs were taken on day one postoperatively and at follow-up at 30 days and 90 days. Radiographs were assessed by 2 evaluators (SMA & GS) for prosthesis position, fracture and subsidence with follow-up radiographs compared against the radiographs taken day one post-operatively. Intraoperative fractures and their treatment were recorded. The incidence of postoperative complications was catagorised into major and minor systemic and local complications using divisions described in previous studies [7,13]. Systemic complications were subdivided into cardiovascular, neurological, pulmonary, urinary, fluid and electrolyte imbalances and general complications. Local complications were subdivided into dislocations, fractures, soft tissue infection and wound haematoma. Statistical analysis using IBM SPSS (Version 21) software was undertaken using Spearman’s Correlation Test to correlate variables against complication rates with significance attributed at the 0.05 level. For any single variable demonstrating a significant correlation, a multivariant logistical regression analysis was undertaken. Variables assessed were patient age, gender, ASA grade, femoral component, acetabular component and femoral head component material. Oxford Hip Scores were recorded for all patients preoperatively and at 90-day follow-up. Results 153 patients were used in this study with no patients lost to followup. The mean age of patient was 84.5 years (range 80–95 years). There were 33 males and 120 females within the cohort. Fig. 1 outlines the percentage of major systemic co-morbidities within the cohort. Median ASA was 2. Fig. 2 outlines the percentages of the ASA grades within the cohort. The mean length of stay was 5.8 days (n = 148, range 3–12 days). 142 patients (93%) underwent THA under General Anaesthesia (GA) with 11 patients (7%) having Spinal Anaesthesia. 144 patients had Corail femoral components with 9 patients having Profemur Gladiator femoral stems. Mean preoperative Oxford Hip Score was 24 (n = 148, range 4–41) and 90-day postoperative score was 46 (n = 145, range 9–48). 45 patients (29%) required further medical investigation prior to surgery following review by the Consultant Physician; 4 patients had 100
Percentage of Cohort
90 80 70 60 50 40 30 20 10 0
Co-Morbidities Fig. 1. Major systemic co-morbidities of the cohort.
9%
7%
ASA 1 ASA 2 ASA 3
84%
Fig. 2. Percentage of ASA grades represented within the cohort.
their surgery postponed whilst they were medically optimised before undergoing surgery. A further 2 patients did not undergo surgery as their risk of severe morbidity or mortality, both secondary to significant cardiovascular disease, was deemed too high by the Consultant Physician in consultation with the Anaesthetist. There were 2 Greater Trochanteric fractures sustained intraoperatively with 1 treated conservatively and 1 with tension band wires. All patients were mobilised fully weight bearing postoperatively. Table 1 outlines the complications over the first 90 days postoperatively. Of note two falls sustained within 30 days resulted in a greater trochanteric and periprosthetic fracture both requiring surgical fixation. At 90 days, there was 1 dislocation as a result of a fall and acetabular fracture with cup migration, with the patient undergoing revision total hip arthroplasty. Prior to this, at 30-day follow-up, the cup was well fixed with no acetabular fracture observed. There was a significant correlation between ASA and the inpatient complication rate (Spearman’s Correlation P = 0.017). No correlation was found in the cohort between any variable and overall 90-day complication rate. Logistical regression analysis demonstrated that ASA grade independently predicted in-patient complications. Increasing the ASA by 1 grade increased the likelihood of developing an inpatient complication by 4.34 times. Discussion Whilst studies have demonstrated that outcomes of the elderly are equal to their younger counterparts when undergoing THA, it comes at the expense of a greater complication risk [6,7,13–15]. This study demonstrates an overall complication rate lower than previous studies done on a similar, elderly cohort of patients. Recent studies have focused on inpatient complications within the elderly population following THA [8,14,16,17]. Our study demonstrates a 3.9% inpatient major systemic complication rate with no major local complications. There was a 7.2% minor systemic complication rate and 0.65% minor local complication rate as inpatients. In studies that report inpatient complications, rates range from 12.5% to 48% with local complication rates ranging from 1% to19%. To our knowledge, few studies document detailed inpatient complication rates specifically in the elderly cohort (N 80 years of age) [8,14,17–19]. Over the 90 day follow-up period there were a 4.6% overall major systemic complication rate and a 1.3% major local complication rate. The only study to report 90-day morbidity rates was in a cohort of patients including total hip and knee primary arthroplasties between 65 and 94 years of age [20]. This study showed a local complication rate of 19% and major complication rate of 11%. The mortality in our cohort was 0.65% at 90 days. Hunt et al recently published data on 409,096 patients that showed a mortality rate of 1.35% in the over 80-year age group undergoing elective THA.
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Table 1 Outlines Postoperative Complications Over the 90-Day Postoperative Period. Major Systemic Complications Mortality Cardiovascular
Neurological Pulmonary Minor Systemic Complications Cardiovascular Neurological Urinary Fluid and electrolyte imbalance General Major Local Complications Dislocation Post Operative Fracture Deep Soft Tissue Infection Minor Local Complications Wound haematoma
Inpatient Complications
Complications at 30 Days
Complications at 90 Days
1 Atrial fibrillation Arrhythmia Deep Vein Thrombosis Pulmonary embolism Stroke Lower Respiratory Tract Infection
3 1
Hypotension Confusion/delirium Urinary tract infection Urinary retention Hyponatraemia Fall
1 1 3 2 3 1
3
0
2 0
Our overall dataset shows a lower morbidity and mortality rate than the published data. Previous research has looked at patient groups who have undergone a mixture of cemented/uncemented prosthesis as inpatients within this age range [7,8,19]. The use of cement in Total Joint Arthroplasty (TJA) is a known risk factor for cardiovascular events postoperatively [21]. A recent study amongst patients undergoing hip hemiarthroplasty for fractured neck of femur has further highlighted the morbidity associated with bone cement implantation syndrome [22]. The fact that our patients underwent uncemented THA, removes this risk factor and may account for the low cardiovascular events that occurred. There were no myocardial infarctions, and only 1.3% had a symptomatic deep vein thrombosis or pulmonary embolism with only 2.6% having an arrhythmia, all of which resolved. Although it may be the case that with age a patient is more likely to have increasing co-morbidities, our data demonstrate that age should not be used as reason alone for denial of elective THA, provided diligent perioperative evaluation is undertaken. Both Consultant Anaesthetist and Physician routinely see all patients above 80 years of age prior to surgery within our unit, allowing for optimisation of the patients and their co-morbidities by clinicians experienced in the management of patients undergoing THA. The correlation between ASA, determined by the anaesthetist, and inpatient complication demonstrates how experienced clinicians can predict post-operative complications and therefore put provisions in place accordingly. Recent studies suggest that spinal anaesthesia is a safer alternative when compared to general anaesthesia in TJA [4,23–25]. Specifically, meta-analyses suggest that it offers advantages in terms of postoperative mortality, thromboembolic disease, lower rates of myocardial infarction and confusion [4,24,25]. The vast majority of our patients had THA under GA (93%) and not spinal anaesthesia. Despite this fact, our mortality and complication rates remain low with 0.65% confusion, stroke, deep vein thrombosis and pulmonary embolism rates. Careful patient optimisation, surgical technique, and prosthesis choice are all likely to account for this low morbidity and mortality in this cohort. Uncemented THA has been shown to have a higher intraoperative femoral fracture rate ranging from 3% to 13% [26–30]. However, these fracture rates were on patients with a wide range of ages, and to our knowledge there is no study reporting intraoperative rates in the over 80 years old cohort. Our fracture rate was 1.3%. Given the age of our population, a high incidence of intraoperative fracture is to be expected due to decreased bone strength with age. Diligent preoperative templating to ensure correct prosthesis sizing
1 1 1 1
2
2
1
4 1 0
1
and together with graduating, incrementally increasing, rasping of the femur, helps to reduce the risk of perioperative fracture. A collared prosthesis has been shown to result in less subsidence and to have greater immediate stability [12,31,32]. If there is concern over bone quality intraoperatively, the use of a collared prosthesis allows for less aggressive rasping of the femur and the use of a slightly smaller femoral stem size. The radial force of the implant will as a result be reduced, and the collar support on the calcar will also resist the tendency for subsidence. We found no evidence of subsidence secondary to fracture when using the collared prosthesis and furthermore; there was no impact on clinical outcome in these patients. All patients were full weight bearing immediately post operatively with excellent 90-day Oxford Hip Scores. With the use of an uncemented collared prosthesis, provided the fracture is adequately fixed during the operation, the collared design provides added stability without limiting postoperative mobilisation. In our cohort falls accounted for two fractures – one greater trochanter fracture and one periprosthetic fracture – and one dislocation with acetabular cup migration. All 3 patients gave a clear history of mechanical fall prior to fracture or dislocation. It is well documented that risk of falls increases with age, and the risk of injury from falls is highest in those over 85 years of age and is often a sign of poor health [33,34]. As our patient group consisted of elective patients with the vast majority being ASA 2, they were generally in good health, but the high risk of falls remains. Furthermore, the actual number of falls is likely to be higher, but under reported if the patient doesn’t suffer serious injury or if the patient attends another hospital. The overall incidence of falls in our cohort was low (4.6%), but of those who fell 43% required further surgery. A study done by Jørgensen et al on elderly patients undergoing THA and TKA’s found most surgery-related falls occur within the first 30 days post-operation [35]. They suggest that interventions aimed at fall prevention be targeted to patients within the first 30 days post-operation. Our study highlights this risk of falls and there may be a need for a comprehensive falls assessment post-operatively in the elderly undergoing TJA. The authors recognise that causal relationships cannot be ascertained by this study type. Randomised control trials would be needed to further look into these possible links. However, collared uncemented THAs in our population were safe and effective when compared to other studies to-date. Our population was reasonably healthy with the majority ASA 2. This may not represent the general elderly population undergoing THA as a whole and this cohort has not been well researched. A single, high volume Consultant Hip Surgeon operated on all the patients. As such, it remains questionable whether these results would
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be applicable in lower volume centres, however this study does provide evidence that experienced practitioners can produce excellent outcomes with uncemented collared prosthesis in the elderly cohort.
Conclusion This study highlights the use of collared uncemented prosthesis in the elderly population. It demonstrates an excellent short-term postoperative complication rate, low mortality rate and good functional outcomes in our cohort. ASA, not age correlates with complications, which serves to demonstrate that co-morbidities should be used to assess patient suitability for THA. In order to accurately determine operative suitability, experienced anaesthetists and physicians should assess all elderly patients to stratify risk and optimise treatment perioperatively. The collared femoral component provides added stability and negates the risk of subsidence. Within the elderly population, with decreased bone strength and increase risk of intraoperative fracture, the collar provides additional support without compromising function. Total Hip Arthroplasty in the elderly is a safe and effective operation. Provided that patient selection, perioperative care and implant selection are optimised, functional outcomes are good and immediate and complications can be minimised.
References 1. No author listed, “What does the 2011 Census tell us about the ‘oldest old’ living in England & Wales?” Office of National Statistics, 2013 2. Culliford DJ, Maskell J, Beard DJ, et al. Temporal trends in hip and knee replacement in the United Kingdom: 1991 to 2006. J Bone Joint Surg (Br) 2010;92(1):130. 3. Ravi B, Croxford R, Reichmann WM, et al. The changing demographics of total joint arthroplasty recipients in the United States and Ontario from 2001 to 2007. Best Pract Res Clin Rheumatol 2012;26(5):637. 4. Hunt LP, Ben-Shlomo Y, Clark EM, et al. 90-day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis. Lancet 2013;382(9898):1097. 5. Madhok R, Lewallen DG, Wallrichs SL, et al. Trends in the utilization of primary total hip arthroplasty, 1969 through 1990: a population-based study in Olmsted County, Minnesota. Mayo Clin Proc 1993;68(1):11. 6. Jones CA, Voaklander DC, Johnston DW, et al. The effect of age on pain, function, and quality of life after total hip and knee arthroplasty. Arch Intern Med 2001; 161(3):454. 7. Parvizi J, Mui A, Purtill JJ, et al. Total joint arthroplasty: when do fatal or near-fatal complications occur? J Bone Joint Surg Am 2007;89(1):27. 8. Nanjayan SK, Swamy GN, Yellu S, et al. In-hospital complications following primary total hip and knee arthroplasty in octogenarian and nonagenarian patients. J Orthop Traumatol 2014;15:29–33. 9. Jacobs CA, Christensen CP. Progressive subsidence of a tapered, proximally coated femoral stem in total hip arthroplasty. Int Orthop 2008;33(4):917. 10. Taunt Jr CJ, Finn H, Baumann P. Immediate weight bearing after cementless total hip arthroplasty. Orthopedics 2008;31(3):223.
11. Kaptoge S, Dalzell N, Loveridge N, et al. Effects of gender, anthropometric variables, and aging on the evolution of hip strength in men and women aged over 65. Bone 2003;32(5):561. 12. Demey G, Fary C, Lustig S, et al. Does a collar improve the immediate stability of uncemented femoral hip stems in total hip arthroplasty? A bilateral comparative cadaver study. J Arthroplasty 2011;26(8):1549. 13. Pulido L, Parvizi J, Macgibeny M, et al. In hospital complications after total joint arthroplasty. J Arthroplasty 2008;23(6 Suppl 1):139. 14. Clement ND, MacDonald D, Howie CR, et al. The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more. J Bone Joint Surg (Br) 2011;93(9):1265. 15. Brander VA, Malhotra S, Jet J, et al. Outcome of hip and knee arthroplasty in persons aged 80 years and older. Clin Orthop 1997;345:67. 16. Newington DP, Bannister GC, Fordyce M. Primary total hip replacement in patients over 80 years of age. J Bone Joint Surg (Br) 1990;72(3):450. 17. Wurtz LD, Feinberg JR, Capello WN, et al. Elective primary total hip arthroplasty in octogenarians. J Gerontol A Biol Sci Med Sci 2003;58(5):M468. 18. Petersen VS, Solgaard S, Simonsen B. Total hip replacement in patients aged 80 years and older. J Am Geriatr Soc 1989;37(3):219. 19. Mnatzaganian G, Ryan P, Norman PE, et al. Total joint replacement in men: old age, obesity and in-hospital complications. ANZ J Surg 2013;83(5):376. 20. Higuera CA, Elsharkawy K, Klika AK, et al. 2010 Mid-America Orthopaedic Association Physician in Training Award: predictors of early adverse outcomes after knee and hip arthroplasty in geriatric patients. Clin Orthop 2011;469(5):1391. 21. Donaldson AJ, Thomson HE, Harper NJ, et al. Bone cement implantation syndrome. Br J Anaesth 2009;102(1):12. 22. Rutter PD, Panesar SS, Darzi A, et al. What is the risk of death or severe harm due to bone cement implantation syndrome among patients undergoing hip hemiarthroplasty for fractured neck of femur? A patient safety surveillance study. BMJ Open 2014;4(6): e004853. 23. Deirmengian Carl, Austin M, Deirmengian G. Hip replacements in the very elderly: selecting a suitable candidate. Aging Health 2011;7(6):803. 24. Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials. Br J Anaesth 2000;84(4):450. 25. Rodgers A. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised. BMJ 2000;321(7275): 1493. 26. Fernandez-Fernandez R, García-Elias E, Gil-Garay E. Peroperative fractures in uncemented total hip arthrography: results with a single design of stem implant. Int Orthop 2007;32(3):307. 27. Andrew TA, Flanagan JP, Gerundini M, et al. The isoelastic, noncemented total hip arthroplasty. Preliminary experience with 400 cases. Clin Orthop 1986;206:127. 28. Fitzgerald Jr RH, Brindley GW, Kavanagh BF. The uncemented total hip arthroplasty. Intraoperative femoral fractures. Clin Orthop 1988;235:61. 29. Martell JM, Pierson III RH, Jacobs JJ, et al. Primary total hip reconstruction with a titanium fiber-coated prosthesis inserted without cement. J Bone Joint Surg Am 1993;75(4):554. 30. Toni A, Ciaroni D, Sudanese A, et al. Incidence of intraoperative femoral fracture. Straight-stemmed versus anatomic cementless total hip arthroplasty. Acta Orthop Belg 1994;60(1):43. 31. Sudhahar T, Morapudi S, Branes K, et al. “Evaluation of subsidence between collarless and collared Corail femoral cement less total hip replacement”. J Orthop 2009;vol. 6, no. 2. 32. Abdul Kadir M, Kamsah N, Mohlisun N. Interface micromotion of cementless hip arthroplasty: collared vs non-collared stems. IFMBE Proc 2008;21:428. 33. Fuller GF. Falls in the elderly. Am Fam Physician 2000;61(7):2159 [2173–2174]. 34. Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas 2013;75(1):51. 35. Jørgensen CC, Kehlet H, Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Collaborative Group. Fall-related admissions after fast-track total hip and knee arthroplasty — cause of concern or consequence of success? Clin Interv Aging 2013;8:1569.
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Primary Collared Uncemented Total Hip Arthroplasties in the Elderly: A Safe and Reliable Treatment Option Gavin Schaller, MBBS, BSc(Hons), MRCS a, Jonathon Black, MBBS, MSc, MRCS a, Asaad Asaad, MD, MSc, MRCS a, Nick Harper, MBBS, FRCA, FFICM a, Stuart Webb, BSc, MD, FRCP b, Sarah Muirhead-Allwood, BSc(Hons), MBBS, FRCS a a b
The London Hip Unit, London, England King Edward VII's Hospital Sister Agnes, London, England
a r t i c l e
i n f o
Article history: Received 6 August 2014 Accepted 5 October 2014 Keywords: primary total hip arthroplasty uncemented total hip arthroplasty octogenarian nonagenarian collared femoral prosthesis
a b s t r a c t The age of patients undergoing primary Total Hip Arthroplasty (THA) remains fairly constant despite an increasingly elderly population, possibly owing to concern over postoperative complications. This study evaluated 90-day outcomes in patients over 80, undergoing uncemented collared primary THA for osteoarthritis in a high volume unit. Data were recorded from 153 consecutive patients. There were 0.65% mortality rate and 1.3% major systemic complication rate. American Society of Anesthesiologist (ASA) grade was an independent predictor of inpatient complications. Mean preoperative and 90-day postoperative Oxford Hip Score was 24 and 46 respectively. No radiological evidence of femoral stem migration was seen. Our cohort shows low morbidity and mortality rates. ASA not age helps predict inpatient complications. Uncemented collared femoral prosthesis resulted in excellent functional and radiological outcomes. © 2014 Elsevier Inc. All rights reserved.
Within Western Society there continues to be an increase in the population of octogenerians and nonagenarians, with those over the age of 85 years the fastest growing group in England and Wales [1]. The number of primary Total Hip Arthroplasties (THAs) has been steadily increasing over the past few decades internationally [2–5]. Those over 85 years of age are as willing as younger cohorts to undergo surgery and gain as much function and pain relief following surgery [6]. Despite this however, studies have found the mean age of patients undergoing THA to be fairly constant or even falling [2,3]. This may reflect a hesitancy to perform major elective surgery on older patients out of concern of co-morbidities and of higher rates of post-operative complications [6–8]. Uncemented femoral prosthesis can undergo complications within the short term with regards to subsidence of the femoral stem, loosening with fibrous ingrowth at the bone–implant interface and a risk of periprosthetic fracture before bony ingrowth has occurred [9,10]. Theoretically this risk is increased within the elderly population who have decreased bone density and bone strength and therefore have a greater risk of bony expansion around the femoral prosthesis [11]. Within this cohort (N80 years of age), a collared uncemented femoral component is routinely used at our unit to mitigate these short term risks and allow for early mobilisation [12].
The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2014.10.004. Reprint requests: Gavin Schaller, MBBS, BSc(Hons), MRCS, The London Hip Unit, 30 Devonshire St, London, England, W1G 6PU. http://dx.doi.org/10.1016/j.arth.2014.10.004 0883-5403/© 2014 Elsevier Inc. All rights reserved.
The objective for this study was to evaluate the 90-day complication rate in the elderly population undergoing uncemented collared primary THA for osteoarthritis within our single surgeon unit. Materials and Methods Over a period of 60 months, data from a consecutive cohort of patients over the age of 80 years and operated on by a single surgeon were recorded. Only primary THAs done for osteoarthritis were included in the study. After being preoperatively accessed by both a Consultant Physician and Consultant Anaesthetist, all patients were operated on by a single, high volume Consultant Hip Surgeon (SMA) using a mini posterior approach. The THA was carried out under general anaesthesia or spinal epidural. Uncemented collared femoral components were used in all patients. Two types of collared prosthesis were used (Corail, Depuy and Profemur Gladiator, Wright Medical). The choice of femoral prosthesis was determined during preoperative planning based upon patient anatomy with the Profemur Gladiator stem chosen for short femoral necks on templating. All acetabular cups were uncemented. Patients had a drain placed that was removed 24 h postoperatively. Thromboprophylaxis was administered with TED stockings, intermittent compression device and enoxaparin given daily as an inpatient. Antibiotics were given on induction and 2 doses postoperatively. Postoperative bloods and check radiograph were taken on the first day after surgery and all patients were mobilised either on the day of surgery or day 1 postoperatively fully weight bearing. On discharge prior to June 2009 all patients were discharged with a daily dose of 75 mg aspirin for
408
G. Schaller et al. / The Journal of Arthroplasty 30 (2015) 407–410
4 weeks. Our protocol changed after this date, with patients’ discharged to take Rivaroxaban for 4 weeks. Patient demographic data together with the preoperative American Society of Anesthesiologist (ASA) grade were recorded. The inpatient length of stay and complications over the first 90 days were recorded along with any readmissions within this time period. Antero-posterior radiographs were taken on day one postoperatively and at follow-up at 30 days and 90 days. Radiographs were assessed by 2 evaluators (SMA & GS) for prosthesis position, fracture and subsidence with follow-up radiographs compared against the radiographs taken day one post-operatively. Intraoperative fractures and their treatment were recorded. The incidence of postoperative complications was catagorised into major and minor systemic and local complications using divisions described in previous studies [7,13]. Systemic complications were subdivided into cardiovascular, neurological, pulmonary, urinary, fluid and electrolyte imbalances and general complications. Local complications were subdivided into dislocations, fractures, soft tissue infection and wound haematoma. Statistical analysis using IBM SPSS (Version 21) software was undertaken using Spearman’s Correlation Test to correlate variables against complication rates with significance attributed at the 0.05 level. For any single variable demonstrating a significant correlation, a multivariant logistical regression analysis was undertaken. Variables assessed were patient age, gender, ASA grade, femoral component, acetabular component and femoral head component material. Oxford Hip Scores were recorded for all patients preoperatively and at 90-day follow-up. Results 153 patients were used in this study with no patients lost to followup. The mean age of patient was 84.5 years (range 80–95 years). There were 33 males and 120 females within the cohort. Fig. 1 outlines the percentage of major systemic co-morbidities within the cohort. Median ASA was 2. Fig. 2 outlines the percentages of the ASA grades within the cohort. The mean length of stay was 5.8 days (n = 148, range 3–12 days). 142 patients (93%) underwent THA under General Anaesthesia (GA) with 11 patients (7%) having Spinal Anaesthesia. 144 patients had Corail femoral components with 9 patients having Profemur Gladiator femoral stems. Mean preoperative Oxford Hip Score was 24 (n = 148, range 4–41) and 90-day postoperative score was 46 (n = 145, range 9–48). 45 patients (29%) required further medical investigation prior to surgery following review by the Consultant Physician; 4 patients had 100
Percentage of Cohort
90 80 70 60 50 40 30 20 10 0
Co-Morbidities Fig. 1. Major systemic co-morbidities of the cohort.
9%
7%
ASA 1 ASA 2 ASA 3
84%
Fig. 2. Percentage of ASA grades represented within the cohort.
their surgery postponed whilst they were medically optimised before undergoing surgery. A further 2 patients did not undergo surgery as their risk of severe morbidity or mortality, both secondary to significant cardiovascular disease, was deemed too high by the Consultant Physician in consultation with the Anaesthetist. There were 2 Greater Trochanteric fractures sustained intraoperatively with 1 treated conservatively and 1 with tension band wires. All patients were mobilised fully weight bearing postoperatively. Table 1 outlines the complications over the first 90 days postoperatively. Of note two falls sustained within 30 days resulted in a greater trochanteric and periprosthetic fracture both requiring surgical fixation. At 90 days, there was 1 dislocation as a result of a fall and acetabular fracture with cup migration, with the patient undergoing revision total hip arthroplasty. Prior to this, at 30-day follow-up, the cup was well fixed with no acetabular fracture observed. There was a significant correlation between ASA and the inpatient complication rate (Spearman’s Correlation P = 0.017). No correlation was found in the cohort between any variable and overall 90-day complication rate. Logistical regression analysis demonstrated that ASA grade independently predicted in-patient complications. Increasing the ASA by 1 grade increased the likelihood of developing an inpatient complication by 4.34 times. Discussion Whilst studies have demonstrated that outcomes of the elderly are equal to their younger counterparts when undergoing THA, it comes at the expense of a greater complication risk [6,7,13–15]. This study demonstrates an overall complication rate lower than previous studies done on a similar, elderly cohort of patients. Recent studies have focused on inpatient complications within the elderly population following THA [8,14,16,17]. Our study demonstrates a 3.9% inpatient major systemic complication rate with no major local complications. There was a 7.2% minor systemic complication rate and 0.65% minor local complication rate as inpatients. In studies that report inpatient complications, rates range from 12.5% to 48% with local complication rates ranging from 1% to19%. To our knowledge, few studies document detailed inpatient complication rates specifically in the elderly cohort (N 80 years of age) [8,14,17–19]. Over the 90 day follow-up period there were a 4.6% overall major systemic complication rate and a 1.3% major local complication rate. The only study to report 90-day morbidity rates was in a cohort of patients including total hip and knee primary arthroplasties between 65 and 94 years of age [20]. This study showed a local complication rate of 19% and major complication rate of 11%. The mortality in our cohort was 0.65% at 90 days. Hunt et al recently published data on 409,096 patients that showed a mortality rate of 1.35% in the over 80-year age group undergoing elective THA.
G. Schaller et al. / The Journal of Arthroplasty 30 (2015) 407–410
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Table 1 Outlines Postoperative Complications Over the 90-Day Postoperative Period. Major Systemic Complications Mortality Cardiovascular
Neurological Pulmonary Minor Systemic Complications Cardiovascular Neurological Urinary Fluid and electrolyte imbalance General Major Local Complications Dislocation Post Operative Fracture Deep Soft Tissue Infection Minor Local Complications Wound haematoma
Inpatient Complications
Complications at 30 Days
Complications at 90 Days
1 Atrial fibrillation Arrhythmia Deep Vein Thrombosis Pulmonary embolism Stroke Lower Respiratory Tract Infection
3 1
Hypotension Confusion/delirium Urinary tract infection Urinary retention Hyponatraemia Fall
1 1 3 2 3 1
3
0
2 0
Our overall dataset shows a lower morbidity and mortality rate than the published data. Previous research has looked at patient groups who have undergone a mixture of cemented/uncemented prosthesis as inpatients within this age range [7,8,19]. The use of cement in Total Joint Arthroplasty (TJA) is a known risk factor for cardiovascular events postoperatively [21]. A recent study amongst patients undergoing hip hemiarthroplasty for fractured neck of femur has further highlighted the morbidity associated with bone cement implantation syndrome [22]. The fact that our patients underwent uncemented THA, removes this risk factor and may account for the low cardiovascular events that occurred. There were no myocardial infarctions, and only 1.3% had a symptomatic deep vein thrombosis or pulmonary embolism with only 2.6% having an arrhythmia, all of which resolved. Although it may be the case that with age a patient is more likely to have increasing co-morbidities, our data demonstrate that age should not be used as reason alone for denial of elective THA, provided diligent perioperative evaluation is undertaken. Both Consultant Anaesthetist and Physician routinely see all patients above 80 years of age prior to surgery within our unit, allowing for optimisation of the patients and their co-morbidities by clinicians experienced in the management of patients undergoing THA. The correlation between ASA, determined by the anaesthetist, and inpatient complication demonstrates how experienced clinicians can predict post-operative complications and therefore put provisions in place accordingly. Recent studies suggest that spinal anaesthesia is a safer alternative when compared to general anaesthesia in TJA [4,23–25]. Specifically, meta-analyses suggest that it offers advantages in terms of postoperative mortality, thromboembolic disease, lower rates of myocardial infarction and confusion [4,24,25]. The vast majority of our patients had THA under GA (93%) and not spinal anaesthesia. Despite this fact, our mortality and complication rates remain low with 0.65% confusion, stroke, deep vein thrombosis and pulmonary embolism rates. Careful patient optimisation, surgical technique, and prosthesis choice are all likely to account for this low morbidity and mortality in this cohort. Uncemented THA has been shown to have a higher intraoperative femoral fracture rate ranging from 3% to 13% [26–30]. However, these fracture rates were on patients with a wide range of ages, and to our knowledge there is no study reporting intraoperative rates in the over 80 years old cohort. Our fracture rate was 1.3%. Given the age of our population, a high incidence of intraoperative fracture is to be expected due to decreased bone strength with age. Diligent preoperative templating to ensure correct prosthesis sizing
1 1 1 1
2
2
1
4 1 0
1
and together with graduating, incrementally increasing, rasping of the femur, helps to reduce the risk of perioperative fracture. A collared prosthesis has been shown to result in less subsidence and to have greater immediate stability [12,31,32]. If there is concern over bone quality intraoperatively, the use of a collared prosthesis allows for less aggressive rasping of the femur and the use of a slightly smaller femoral stem size. The radial force of the implant will as a result be reduced, and the collar support on the calcar will also resist the tendency for subsidence. We found no evidence of subsidence secondary to fracture when using the collared prosthesis and furthermore; there was no impact on clinical outcome in these patients. All patients were full weight bearing immediately post operatively with excellent 90-day Oxford Hip Scores. With the use of an uncemented collared prosthesis, provided the fracture is adequately fixed during the operation, the collared design provides added stability without limiting postoperative mobilisation. In our cohort falls accounted for two fractures – one greater trochanter fracture and one periprosthetic fracture – and one dislocation with acetabular cup migration. All 3 patients gave a clear history of mechanical fall prior to fracture or dislocation. It is well documented that risk of falls increases with age, and the risk of injury from falls is highest in those over 85 years of age and is often a sign of poor health [33,34]. As our patient group consisted of elective patients with the vast majority being ASA 2, they were generally in good health, but the high risk of falls remains. Furthermore, the actual number of falls is likely to be higher, but under reported if the patient doesn’t suffer serious injury or if the patient attends another hospital. The overall incidence of falls in our cohort was low (4.6%), but of those who fell 43% required further surgery. A study done by Jørgensen et al on elderly patients undergoing THA and TKA’s found most surgery-related falls occur within the first 30 days post-operation [35]. They suggest that interventions aimed at fall prevention be targeted to patients within the first 30 days post-operation. Our study highlights this risk of falls and there may be a need for a comprehensive falls assessment post-operatively in the elderly undergoing TJA. The authors recognise that causal relationships cannot be ascertained by this study type. Randomised control trials would be needed to further look into these possible links. However, collared uncemented THAs in our population were safe and effective when compared to other studies to-date. Our population was reasonably healthy with the majority ASA 2. This may not represent the general elderly population undergoing THA as a whole and this cohort has not been well researched. A single, high volume Consultant Hip Surgeon operated on all the patients. As such, it remains questionable whether these results would
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be applicable in lower volume centres, however this study does provide evidence that experienced practitioners can produce excellent outcomes with uncemented collared prosthesis in the elderly cohort.
Conclusion This study highlights the use of collared uncemented prosthesis in the elderly population. It demonstrates an excellent short-term postoperative complication rate, low mortality rate and good functional outcomes in our cohort. ASA, not age correlates with complications, which serves to demonstrate that co-morbidities should be used to assess patient suitability for THA. In order to accurately determine operative suitability, experienced anaesthetists and physicians should assess all elderly patients to stratify risk and optimise treatment perioperatively. The collared femoral component provides added stability and negates the risk of subsidence. Within the elderly population, with decreased bone strength and increase risk of intraoperative fracture, the collar provides additional support without compromising function. Total Hip Arthroplasty in the elderly is a safe and effective operation. Provided that patient selection, perioperative care and implant selection are optimised, functional outcomes are good and immediate and complications can be minimised.
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