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

Joshua A. Bell; Ahmed K. Emara; Wael K. Barsoum; Michael Bloomfield; Isaac Briskin; Carlos Higuera; Alison K. Klika; Viktor E. Krebs; Nathan W. Mesko; Robert M. Molloy; Michael A. Mont; Trevor G. Murray; George F. Muschler; Robert J. Nickodem; Preetesh D. Patel; Jonathan L. Schaffer; Kim L. Stearns; Gregory J. Strnad; Nicolas S. Piuzzi

doi:10.1055/s-0042-1748821

The Journal of Knee Surgery, Table of Contents

J Knee Surg 2023; 36(09): 1001-1011
DOI: 10.1055/s-0042-1748821

Original Article

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

Authors

Joshua A. Bell

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Ahmed K. Emara

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Wael K. Barsoum

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Michael Bloomfield

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Isaac Briskin

²Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
Carlos Higuera

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Alison K. Klika

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Viktor E. Krebs

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Nathan W. Mesko

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Robert M. Molloy

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Michael A. Mont

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Trevor G. Murray

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
George F. Muschler

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Robert J. Nickodem

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Preetesh D. Patel

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Jonathan L. Schaffer

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Kim L. Stearns

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Gregory J. Strnad

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
Nicolas S. Piuzzi

¹Department of Orthopaedic Surgery, Orthopedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio

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 readmission

Full Text

References

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