BOSTON, Massachusetts—A prospective cohort study by researchers from Beth Israel Deaconess Medical Center in Boston suggests that physicians should be less reticent about discussing joint replacement surgery with elderly patients.

Lead author Mary Beth Hamel, MD, MPH, of the division of general medicine and primary care, reported in Archives of Internal Medicine that median time to recovery of independence in walking was about 12 days for patients aged 65 to 74 years and for those ≥75, and that both age groups had dramatically lower pain levels at 12 months than similar patients who did not have hip or knee replacements.¹ The investigators also found that 45% of the patients who did not have joint replacement surgery during the study period reported that surgery “had not been offered as a potential treatment by any of their physicians.”

“Many patients were not offered surgery or chose not to have surgery owing to concerns about postoperative complications or prolonged recovery. Improved communication between physicians and patients may allow more elderly patients to make informed choices and to thoughtfully weight the risks and burdens of joint replacement against its benefits in alleviating pain and improving function and quality of life,” Dr. Hamel said.

Old and elderly with arthritis all benefit from joint replacement

The study included 91 patients aged 65 to 74 years and 83 patients aged ≥75. All had severe OA of the hip or knee inadequately controlled with conservative treatments, with a mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) of 56 on a 100-point scale at baseline. OA symptoms and functional status were assessed at baseline and at 12 months. For the 29% of patients who had joint replacement during the 12 months of the study, postoperative symptoms and function were assessed at 6 weeks, 6 months, and 12 months after surgery.

At 12 months, WOMAC scores had improved by 24 points in patients who had joint replacement versus 0.5 points in those who did not have surgery (P <.001). WOMAC scores improved after joint replacement by 27.4 points in patients aged 65 to 74 years and by 18.9 points in those ≥75 years. None of the patients died; 17% had postoperative complications and 38% had pain lasting >4 weeks following surgery.

Patients aged ≥75 took about the same amount of time to return to regular activities as those aged 65 to 74, with most patients requiring assistance with activities such as shopping and household chores for >1 month. The older patients did require assistance in bathing for significantly longer than the 65 to 74-year olds (median time to recovery, 28 days vs 14 days, P = .01)

Poor need more joint replacements, get fewer

Dr. Hamel said that those who did not have surgery tended to be older, have lower incomes, and be more worried about surgical complications and a long recovery than those who did have surgery. The researchers comment, “[O]ur finding that patients with lower incomes were less likely to have surgery is concerning and mirrors many other research findings of diminished access to joint replacement surgery and other effective treatments among patients with lower socioeconomic status. Of note, there are some data to suggest that these differences are not driven by differences in preferences or need for surgery; [one] study found that lower education and income were associated with a greater need for joint replacement but were not associated with less willingness to have surgery.”

“Our findings of excellent outcomes from joint replacement surgery in elderly patients with severe hip or knee osteoarthritis corroborate and extend the findings of previous studies,” the authors conclude. “These data should inform discussion about joint replacement surgery and allow patients to consider the risks and benefits of surgery as well as the expected postoperative recovery experience.”

Reference

1. Hamel MB, Toth M, Legedza A, et al. Joint replacement surgery in elderly patients with severe osteoarthritis of the hip or knee. Decision making, postoperative recovery, and clinical outcomes. Arch Int Med. 2008;168:1430-1440.