Should an Age Cutoff Be Considered for Elective Total Knee Arthroplasty Patients? An Analysis of Operative Success Based on Patient-Reported Outcomes

Abstract

Total knee arthroplasty (TKA) is increasing in the elderly population; however, some patients, family members, and surgeons raise age-related concerns over expected improvement and risks. This study aimed to (1) evaluate the relationship between age and change in patient-reported outcome measures (PROMs); (2) model how many patients would be denied improvements in PROMs if hypothetical age cutoffs were implemented; and (3) assess length of stay (LOS), readmission, reoperation, and mortality per age group. A prospective cohort of 4,396 primary TKAs (August 2015–August 2018) was analyzed. One-year PROMs were evaluated via Knee injury and Osteoarthritis Outcome Score (KOOS)-pain, -physical function short form (-PS), and -quality of life (-QOL), as well as Veterans Rand-12 (VR-12) physical (-PCS) and mental component (-MCS) scores. Positive predictive values (PPVs) of the number of postoperative “failures” (i.e., unattained minimal clinically important difference in PROMs) relative to number of hypothetically denied “successes” from a theoretical age-group restriction was estimated. KOOS-PS and QOL median score improvements were equivalent among all age groups (p = 0.946 and p = 0.467, respectively). KOOS-pain improvement was equivalent for ≥80 and 60–69-year groups (44.4 [27.8–55.6]). Median VR-12 PCS improvements diminished as age increased (15.9, 14.8, and 13.4 for the 60–69, 70–79, and ≥80 groups, respectively; p = 0.002) while improvement in VR-12 MCS was similar among age groups (p = 0.440). PPV for failure was highest in the ≥80 group, yet remained <34% for all KOOS measures. Overall mortality was highest in the ≥80 group (2.14%, n = 9). LOS >2, non-home discharge, and 90-day readmission were highest in the ≥80 group (8.11% [n = 24], p < 0.001; 33.7% [n = 109], p < 0.001; and 34.4% [n = 111], p = 0.001, respectively). Elderly patients exhibited similar improvement in PROMs to younger counterparts despite higher LOS, non-home discharge, and 90-day readmission. Therefore, special care pathways should be implemented for those age groups.

Readmission and Reoperation Following Carpometacarpal Arthroplasty

“…Many of these orthopedic studies have shown obesity and older age, among other risk factors, to be associated with postsurgical readmission. 20 , 21 , 22 , 23 , 24 …”

Patient-Reported Outcome Measures: State of the Art in Patient-Reported Outcome Measure Application in Lower Extremity Orthopaedics

“…In addition, special attention should be paid to high-risk populations, such as obese and elderly patients, who may be denied surgery because of increased complications after arthroplasty. 20,43,44 Using age cutoff values, Bell et al 20 demonstrated that patients older than 80 years experienced more complications; however, most of these patients showed similar improvements in PROMs after TKA compared with their younger counterparts. This illustrates that elderly patients may be denied notable benefits because of withholding TKA based only on their age.…”

“…12 PROMs are increasingly being considered as the ideal tool for clinical decision support and shared decision making. 8,16,18-20…”

Immunonutrition in Orthopedic and Traumatic Patients

“…Several conditions have been identified in the trauma and elective orthopedic settings to explain the failure of professionals’ and patients’ desired goals, with some authors raising age-related concerns over expected improvement and risks [ 6 ]. Poor nutrition status is a serious issue affecting more than 30% of hospitalized patients [ 7 , 8 ], reducing their quality of life, and hindering postoperative functional rehabilitation and fast discharge [ 9 ].…”