Subscribe to RSS
DOI: 10.1055/s-0042-1748821
Should an Age Cutoff Be Considered for Elective Total Knee Arthroplasty Patients? An Analysis of Operative Success Based on Patient-Reported Outcomes
Funding None.![](https://www.thieme-connect.de/media/jks/202309/lookinside/thumbnails/10-1055-s-0042-1748821_210204oa-1.jpg)
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.
Keywords
knee - outcomes - arthroplasty - total knee arthroplasty - patient-reported outcome measures - age - mortality - 90-day readmissionPublication History
Received: 28 April 2021
Accepted: 18 March 2022
Article published online:
10 June 2022
© 2022. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 Adhikary SD, Liu W-M, Memtsoudis SG, Davis III CM, Liu J. Body mass index more than 45 kg/m(2) as a cutoff point is associated with dramatically increased postoperative complications in total knee arthroplasty and total hip arthroplasty. J Arthroplasty 2016; 31 (04) 749-753
- 2 Pallin DJ, Espinola JA, Camargo Jr CAJ. US population aging and demand for inpatient services. J Hosp Med 2014; 9 (03) 193-196
- 3 Siddiqi A, Warren JA, Manrique-Succar J, Molloy RM, Barsoum WK, Piuzzi NS. Temporal trends in revision total hip and knee arthroplasty from 2008 to 2018: gaps and opportunities. J Bone Joint Surg Am 2021; 103 (14) 1335-1354
- 4 Konopka JF, Lee Y-Y, Su EP, McLawhorn AS. Quality-adjusted life years after hip and knee arthroplasty: health-related quality of life after 12,782 joint replacements. JBJS Open Access 2018; 3 (03) e0007-e0007
- 5 Jacobs CA, Christensen CP, Karthikeyan T. Patient and intraoperative factors influencing satisfaction two to five years after primary total knee arthroplasty. J Arthroplasty 2014; 29 (08) 1576-1579
- 6 Kennedy JW, Johnston L, Cochrane L, Boscainos PJ. Total knee arthroplasty in the elderly: does age affect pain, function or complications?. Clin Orthop Relat Res 2013; 471 (06) 1964-1969
- 7 Zicat B, Rorabeck CH, Bourne RB, Devane PA, Nott L. Total knee arthroplasty in the octogenarian. J Arthroplasty 1993; 8 (04) 395-400
- 8 Miric A, Inacio MCS, Kelly MP, Namba RS. Can total knee arthroplasty be safely performed among nonagenarians? An evaluation of morbidity and mortality within a total joint replacement registry. J Arthroplasty 2014; 29 (08) 1635-1638
- 9 Karuppiah SV, Banaszkiewicz PA, Ledingham WM. The mortality, morbidity and cost benefits of elective total knee arthroplasty in the nonagenarian population. Int Orthop 2008; 32 (03) 339-343
- 10 Cleveland O, Piuzzi NS, Strnad G. et al; OME Cleveland Clinic Orthopaedics. Implementing a scientifically valid, cost-effective, and scalable data collection system at point of care: the cleveland clinic OME cohort. J Bone Joint Surg Am 2019; 101 (05) 458-464
- 11 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 (02) 377-381
- 12 Levin JM, Khlopas A, Sodhi N. et al; Cleveland Clinic Orthopaedic Arthroplasty. The association between readmission and patient experience in a total hip arthroplasty population. J Arthroplasty 2018; 33 (06) 1668-1674
- 13 Ramanathan D, Gad BV, Luckett MR, Klika AK, Spindler KP, Higuera CA. Validation of a new web-based system for point-of-care implant documentation in total knee arthroplasty. J Knee Surg 2018; 31 (08) 767-771
- 14 OME Cleveland Clinic Orthopaedics. Value in research: achieving validated outcome measurements while mitigating follow-up cost. J Bone Joint Surg Am 2020; 102 (05) 419-427
- 15 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg 2014; 12 (12) 1495-1499
- 16 Quan H, Li B, Couris CM. et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol 2011; 173 (06) 676-682
- 17 Collins NJ, Prinsen CAC, Christensen R, Bartels EM, Terwee CB, Roos EM. Knee Injury and Osteoarthritis Outcome Score (KOOS): systematic review and meta-analysis of measurement properties. Osteoarthritis Cartilage 2016; 24 (08) 1317-1329
- 18 Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)–development of a self-administered outcome measure. J Orthop Sports Phys Ther 1998; 28 (02) 88-96
- 19 Selim AJ, Rogers W, Fleishman JA. et al. Updated U.S. population standard for the Veterans RAND 12-item Health Survey (VR-12). Qual life Res 2009; 18 (01) 43-52
- 20 Hung M, Bounsanga J, Voss MW, Saltzman CL. Establishing minimum clinically important difference values for the Patient-Reported Outcomes Measurement Information System Physical Function, hip disability and osteoarthritis outcome score for joint reconstruction, and knee injury and osteoarthritis outcome score for joint reconstruction in orthopaedics. World J Orthop 2018; 9 (03) 41-49
- 21 Gornet MF, Copay AG, Sorensen KM, Schranck FW. Assessment of health-related quality of life in spine treatment: conversion from SF-36 to VR-12. Spine J 2018; 18 (07) 1292-1297
- 22 Lyman S, Lee Y-Y, McLawhorn AS, Islam W, MacLean CH. What are the minimal and substantial improvements in the HOOS and KOOS and JR versions after total joint replacement?. Clin Orthop Relat Res 2018; 476 (12) 2432-2441
- 23 McGill R, Tukey JW, Larsen WA. Variations of box plots. Am Stat 1978; 32 (01) 12-16
- 24 Belmar CJ, Barth P, Lonner JH, Lotke PA. Total knee arthroplasty in patients 90 years of age and older. J Arthroplasty 1999; 14 (08) 911-914
- 25 Hughes J. Biomechanics of the through-knee prosthesis. Prosthet Orthot Int 1983; 7 (02) 96-99
- 26 Inacio MCS, Paxton EW, Graves SE, Namba RS, Nemes S. Projected increase in total knee arthroplasty in the United States - an alternative projection model. Osteoarthritis Cartilage 2017; 25 (11) 1797-1803
- 27 Duffin P. Death rate by age and sex in the U.S. 2017 . Statista. Published 2019. Accessed July 2, 2020 at: www.statista.com/statistics/241572/death-rate-by-age-and-sex-in-the-us/
- 28 Kuperman EF, Schweizer M, Joy P, Gu X, Fang MM. The effects of advanced age on primary total knee arthroplasty: a meta-analysis and systematic review. BMC Geriatr 2016; 16: 41
- 29 Pulido L, Parvizi J, Macgibeny M. et al. In hospital complications after total joint arthroplasty. J Arthroplasty 2008; 23 (06, Suppl 1): 139-145
- 30 Alfonso DT, Howell RD, Strauss EJ, Di Cesare PE. Total hip and knee arthroplasty in nonagenarians. J Arthroplasty 2007; 22 (06) 807-811
- 31 Lizaur-Utrilla A, Martinez-Mendez D, Miralles-Muñoz FA, Marco-Gomez L, Lopez-Prats FA. Risk-benefit on quality of life after total knee arthroplasty in octogenarians. J Arthroplasty 2017; 32 (08) 2417-2420
- 32 Joshi AB, Gill G. Total knee arthroplasty in nonagenarians. J Arthroplasty 2002; 17 (06) 681-684
- 33 Pagnano MW, McLamb LA, Trousdale RT. Total knee arthroplasty for patients 90 years of age and older. Clin Orthop Relat Res 2004; (418) 179-183
- 34 Sezgin EA, Robertsson O, W-Dahl A, Lidgren L. Nonagenarians qualify for total knee arthroplasty: a report on 329 patients from the Swedish Knee Arthroplasty Register 2000-2016. Acta Orthop 2019; 90 (01) 53-59
- 35 Ramkumar PN, Navarro SM, Haeberle HS, Ng M, Piuzzi NS, Spindler KP. No difference in outcomes 12 and 24 months after lower extremity total joint arthroplasty: a systematic review and meta-analysis. J Arthroplasty 2018; 33 (07) 2322-2329