Features March 2012 Issue

How Old Is Too Old for Joint Replacement?

Your overall health and quality of life, not your age, should be the driving factors when considering surgery.

Trevor Murray, MD, has replaced joints in people in their late 80s. And, his colleagues in Cleveland Clinic’s Department of Orthopaedic Surgery have performed the operations on centenarians.

These patients exemplify a growing philosophy in orthopaedic surgery: Age is no barrier to joint replacement.

With advances in surgery, anesthesia, and pain management, nearly anyone who’s healthy enough is a candidate for a new knee, hip, or other joint—regardless of age. But you should know the risks and optimize your health before surgery to improve results afterward.

“We certainly are seeing very healthy 70- and 80-year-olds to whom we offer joint-replacement surgery,” Dr. Murray says. “Don’t think that because you’re a certain age you can’t have it done. There’s no ceiling that says absolutely after this age surgery should not be performed.”

Consider the Risks
The odds of complications from any joint replacement increase with age, and older adults don’t handle complications as well as younger patients. Your heart’s ability to recover from trauma—what experts call cardiac reserve—diminishes with each passing year, even if you’re in relatively good health. Thus, any major surgery poses the risk of heart attack and stroke.

More often than their younger counterparts, older patients have chronic medical conditions, such as heart or lung disease, diabetes and anemia, that have been associated with poor surgical outcomes and require special attention. For this reason, work with your primary care physician before your surgery to address any risk factors (e.g. blood pressure, blood sugar, anemia, smoking).

“Any kind of overall general health improvement that you can do in the three to six months prior to surgery will improve your outcome,” Dr. Murray says.

Older adults may take longer to regain mobility after surgery, increasing their risk of complications, such as blood clots. However, this risk has been minimized with the use of inflatable stockings to keep blood circulating in the legs, blood-thinning drugs early in the post-operative period, and more aggressive rehabilitation regimens that get patients up and moving as early as the day of their surgery.

Another concern is post-operative delirium. Older adults are more sensitive to the effects of anesthesia and narcotic pain medications, which can cause confusion and increase the risk of balance problems and falls. Fortunately, most hip and knee replacements can be performed with regional pain blocks that don’t enter the general bloodstream, minimizing cognitive side effects. And, some patients can get by without narcotic pain medications.

“With our newer surgical techniques and better anesthesia and post-operative physical therapy treatment, we’re able to get some people out on just Tylenol,” Dr. Murray says. “If that’s not the case, patients should be on short-acting, low-dose narcotics, if needed, and weaned off them as quickly as possible.”

Preparation and ‘Pre-Hab’
Preparing for joint replacement requires planning for afterward. Based on your pre-operative evaluation, your overall health and your living arrangements, your doctor may recommend that you visit a rehabilitation center to recover from surgery.

If you’re to return directly home, prepare your house in advance. If you have a two-story home, set up a bed downstairs and plan to live only on the ground floor for a while. Get rid of loose rugs and tripping hazards.

“Simplify the living arrangement as much as possible, and have help around,” Dr. Murray says. “If you’re in your 80s, you’ve probably helped a lot of people along the way, so it’s time to call in some favors.”

A key to bouncing back from joint replacement is to build up the muscles around the problem joint as much as possible before surgery—what medical experts refer to as “pre-hab.” Have your doctor or physical therapist recommend strengthening exercises, and stay as active as you can.

For this reason, Dr. Murray recommends that patients consider joint replacement before the pain is so severe that it prohibits physical activity. “You don’t want to wait until you can’t walk,” he says. “If you do, you’re going to have a hard time ever getting back on your feet and walking. So, you want to stay active and see someone before it gets you to the point where you’re no longer mobile.”

Dr. Murray has his joint-replacement patients return to see him three weeks after surgery, and if all is well, again at three months and one year. “By three weeks, you should walk in with just a cane, at six weeks you should be carrying that cane, and at three months you’re 90 percent recovered.”

Time for a New Joint?
Whether you’re 68 or 86, if medications and physical therapy no longer ease the pain of a diseased joint and you no longer can do what you need or want to do, talk with your doctor about joint replacement.

“Consider surgery when your quality of life is greatly diminished,” Dr. Murray advises.