Marc Darrow, MD, JD
I am often asked, “am I too old for knee pain treatment.” In our office we regularly treat elderly patients with knee pain, some patients are in their 90s. In this article I will review current research and our own clinical observations in patient with significant knee pain who happen to be in their 80s and 90s.
Knee replacement outcomes and complications in patients in their 80s and 90s
A June 2022 study (1) assessed the mortality and complication rates in 90 year olds and 80 year olds patients total hip and knee replacement patients. The researchers of this study write: “Advancing age is a significant risk factor for the development of perioperative complications and mortality in patients undergoing total hip or knee replacement due to their compromised health status and the associated medical comorbidities. The researchers of this study wanted to identify if 90 year olds having a total hip and knee replacement have a higher incidence of mortality and morbidity compared to 80 year olds). The researchers found: “Although nonagenarians (90 year olds) undergoing total hip or knee replacement can achieve the same clinical benefit as octogenarians (80 year olds), they have a higher risk of perioperative complications and one-year mortality. Therefore, meticulous preoperative screening, proper patient selection and optimization of comorbidities are essential to minimize any postoperative side effects in patients over 90 years of age.”
Risks of total knee replacement in octogenarians
A January 2022 study (2) examined the risks of total knee replacement in octogenarians and asked “Is age a determining factor in predicting complications?” The researchers write: “There is a direct relationship between the increase in age (older patients) and the prevalence of both functional and cognitive disabling chronic diseases, however, little we know about whether age is an independent factor in predicting worse functional outcomes and readmissions after total knee replacement.” The researchers then determined to evaluate the clinical-functional results and unplanned readmissions within the first 90 postoperative days in patients older than 80 years compared with a control group of patients younger than 80 years. What the researchers found was: “Age as an independent factor proved not to be a predictor (age itself is not a predictor of complication) by itself of unplanned readmissions or worse clinical-functional results in a period of 90 postoperative days between both groups. We believe that the preoperative evaluation of octogenarian patients should be multidisciplinary, with special attention to the identification of comorbidities that can influence the fragility of a patient and the optimization of the pathology.”
Does age matter? Eighty-year-olds and knee replacement
In June 2021 researchers (3) conducted a retrospective observational study in octogenarians who had total knee replacement between 2015 and 2019, comparing preoperative and postoperative Knee Society Score (KSS), Knee Society Function Score (KSFS), extension and flexion balance, and radiologic alignment. In this period 36 patients over the age of 80 years underwent total knee replacement, with a mean age of 81.6 years. Seven patients (19.4%) suffered a medical complication and two patients experienced surgical complications. Four patient died (11.1%) during follow-up. The mean patient survival was 67.4 months. Patients over 80 years did achieve clinical improvement after total knee replacement. Comorbidities, not age, are the burden for surgery in older patients.
A March 2022 study (5) addressed complications, readmission rates, and in-hospital lengths-of-stay in octogenarian vs. non-octogenarians following total knee replacement. This was a study of more than 1.7 million patients. In this research, octogenarians were found to have significantly higher incidence and odds of 90-day readmission rates and significantly longer in-hospital stays compared to controls. Octogenarians also had equal incidence and odds of developing any medical complication and lower incidence and odds of implant-related complications compared to controls.
Same-day discharge in knee replacement patients 80 years old and up
A March 2022 study (4) looked at same-day discharge in knee replacement patients 80 years old and up. The researchers of this paper say “the purpose of this study was to compare 90-day complications and mortality following same-day discharge after primary total knee replacement in patients more than 80 years old and those under 80 years old. Patients who underwent unilateral primary total knee replacement, were discharged same day, and had a minimum 90-day follow-up were examined. These patients were stratified into two cohorts based upon age: (1) nonoctogenarians (<80 years old) and (2) octogenarians (≥80 years old). In total, 1,111 patients were included in each group.
- There was no significant difference in 90-day mortality between the two groups. However, octogenarians were at significantly increased risk of postoperative atrial fibrillation, nonatrial fibrillation arrhythmias, pneumonia, stroke, heart failure, and urinary tract infection compared with the nonoctogenarian cohort. Relative to matched controls, octogenarians were at significantly increased risk of numerous 90-day medical complications following same-day primary primary total knee replacement, including cardiopulmonary complications, stroke, and urinary tract infection.
1 Kitridis D, Tsikopoulos K, Givissis P, Chalidis B. Mortality and complication rates in nonagenarians and octogenarians undergoing total hip and knee arthroplasty: a systematic review and meta-analysis. European Geriatric Medicine. 2022 Jan 24:1-9.
2 Vildoza S, García-Mansilla A, Brandariz R, Holc F, Teves JI, Carbó L, Costantini J. Total knee replacement in octogenarians, Is age a determining factor in predicting complications? a retrospective cohort study. European Journal of Orthopaedic Surgery & Traumatology. 2022 Jan 5:1-5.
3 Trigueros-Larrea JM, Gonzalez-Bedia MA, Lomo-Garrote JM, Martin-de la Cal O, Martin-Ferrero MA. Total knee arthroplasty in octogenarians: should we still be so restrictive?. Geriatrics. 2021 Jun 30;6(3):67.
4 Berger PZ, Gu A, Fassihi SC, Stake S, Bovonratwet P, Gioia C, Palosaari A, Campbell JC, Thakkar SC. Increased Complications in Octogenarians Undergoing Same-Day Discharge following Total Knee Arthroplasty: A Matched Cohort Analysis. The Journal of Knee Surgery. 2022 Mar 8.
5 Varghese PP, Chen C, Gordon AM, Magruder ML, Vakharia RM, Erez O, Razi AE. Complications, readmission rates, and in-hospital lengths-of-stay in octogenarian vs. non-octogenarians following total knee arthroplasty: An analysis of over 1.7 million patients. The Knee. 2022 Mar 1;35:213-9.