Features May 2006 Issue

Are You Too Old For Surgery?

Age is no longer a barrier to joint replacement—as long as the risks are controlled.

Arthritis of the hip and knee become familiar problems as we age, so it’s no surprise that joint-replacement procedures, once considered too risky for older patients, have become some of the most common surgeries for seniors.

“People used to retire to a sedentary life, but now they’re demanding more of old age,” says Kenneth Marks, M.D., an orthopaedic surgeon at The Cleveland Clinic. “Seniors are more active today, and they want to stay active in comfort.”

The benefits of total joint replacement are significant. Free of pain, patients can walk more easily, care for themselves, and resume an active life. Their cardiac health improves, they’re able to control their weight, and their mood lifts. They feel younger and more in control.

But surgery in older people presents risks which must be balanced against the benefits. Thanks to advanced techniques, these risks are usually manageable.

What can go wrong?
Older patients have less cardiac reserve, the ability of the heart to quickly adjust to new demands. If your system is stressed by surgery, you may be at increased risk for an adverse reaction. Major surgery in older adults poses the risk of heart attack, stroke, or blood clotting. In a condition called deep-vein thrombosis, a blood clot forms in a deep vein, commonly in the thigh or calf. A clot that breaks off and travels to an artery in the lungs can cause a blockage called a pulmonary embolism, a situation that can become fatal. Another concern specific to total joint replacement is risk of infection in the new joint, a problem that requires additional surgery to re-implant the joint. Further, older patients need more time for recovery and rehabilitation, and they don’t handle complications as well as younger patients.

Studies have also shown that older patients experience confusion and a decline in memory and other cognitive skills following major surgery. But the problem is most apparent in patients over age 85, and is thought to be related to medication and an unfamiliar hospital environment. Reducing the amount of medication, and using regional blocks that don’t enter the general bloodstream can help. The problem usually subsides when the patient returns home.

Controlling risks
The risks of surgery depend more upon health than age. In an ideal situation, an older candidate for joint replacement will have only hip or knee-joint disease. However, many older patients suffer from other health problems. “They may have congestive heart failure, diabetes, kidney impairment, chronic infections, a history of stroke, neurological problems, or suffer from obesity. Some patients have multiple problems,” explains Dr.  Marks. “A patient with less cardiac reserve, such as someone with a history of congestive heart failure, may experience a recurrence of heart problems when subjected to the stress of surgery.”

But by controlling risks, surgeons are able to perform joint replacement procedures in most elderly patients.

Prior to surgery, a patient will typically undergo a thorough medical evaluation in order to diagnose and correct any existing problems. In addition, strategies have been developed to prevent blood clots following surgery. To keep blood circulating in the legs, the patient will wear an inflatable stocking, receive a low dose of blood-thinners early in the post-operative period, and undergo ultrasound testing to detect any clots that may have developed. If a clot is found, it is treated aggressively with blood thinners. “All these measures are effective,” says Dr. Marks. “Blood clots following surgery used to be a major cause of death, but not so anymore.”

Deciding on surgery
“Total joint replacement is underutilized in the United States. Only a fraction of the people who need the procedure get it,” says Dr. Marks, who has operated on people in their mid-90s, and performed hip replacement on a 102-year-old patient. “One reason is the fear of risks and pain. But both are better controlled than in the past. Most patients’ perception of surgery is 25 years behind the times.”

If your arthritis pain is severe, if medication fails to control it, if you can’t walk more than three blocks, or if pain wakes you at night, consider joint-replacement surgery—no matter how advanced your age.