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Orthopedic Surgery in Elderly Patients: Past, Present, and Future

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (16 December 2022) | Viewed by 19155

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Dr. Dietmar Dammerer

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Department for Orthopaedics and Traumatology, University Hospital Krems, 3500 Krems, Austria
Interests: hip arthroplasty; orthopedic surgery; revision arthroplasty; orthopedic oncology; general orthopedics

Special Issue Information

Dear Colleagues,

In orthopedic surgery, the elderly patient represents a great challenge for the surgeon in an operating room. In addition to complications related to various factors, such as patient age, general health status, poor bone quality, sarcopenia, and decreased mobility, the number of older patients is steadily increasing. The medical comorbidities and perioperative risks in elderly patients become more complex and challenging in orthopedic co-management.

Nevertheless, total hip and knee joint replacement is one of the most successful surgical procedures in the field of orthopedic surgery. The number of joint replacements is increasing year by year; however, the problem of increasing numbers of revision surgeries due to implant loosening, periprosthetic fractures or infections, and implant-related failures (e.g., wear) remains a great challenge for the surgeon and the orthogeriatric team.

Based on the current literature, the orthopedic treatment of elderly patients is expected to have a strong impact on the economic burden of the public healthcare system. Therefore, an organized, coordinated, and multidisciplinary approach to the perioperative management of these patients will result in fewer complications, improved outcomes, and reduced mortality, disability, and cost of care.

All in all, orthopedic surgery in elderly patients will remain challenging and demanding for the entire orthopedic team. On this account, we are very pleased to announce a Special Issue of the Journal of Clinical Medicine entitled “Orthopedic Surgery in Elderly Patients: Past, Present, and Future”.

Dr. Dietmar Dammerer
Guest Editor

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Keywords

elderly patient
geriatric patient
orthogeriatric
orthopaedic surgery
orthopedic surgery
orthopaedic surgery in the elderly
total joint replacement
total joint arthroplasty
fragility fractures
osteoporosis

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Published Papers (8 papers)

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Research

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12 pages, 1484 KiB

Open AccessArticle

Mid-Term Migration Behavior of an Uncemented Proximally Anchored Straight Stem—A Retrospective EBRA Migration Analysis

by Philipp Blum, Johannes Neugebauer, Alexander Keiler, David Putzer, Julius Watrinet, Sebastian Biermeier and Dietmar Dammerer

J. Clin. Med. 2023, 12(13), 4335; https://doi.org/10.3390/jcm12134335 - 28 Jun 2023

Viewed by 1190

Abstract

Background: Aseptic loosening is one of the most-common causes of the failure of cementless stems. Einzel Bild Röntgen Analyse-Femoral Component Analysis (EBRA-FCA) allows the diagnosis of stem migration, which can be considered a factor in predicting implant survival. The current study aimed to present the migration behavior of a tapered proximally anchored straight stem. Methods: This retrospective study reviewed all consecutive patients who received a cementless CBC straight stem (Mathys AG, Bettlach, Switzerland) between 2005 and 2019. We analyzed the migration pattern using the EBRA-FCA software and reviewed their medical histories. In addition, periprosthetic radiolucency was rated according to the Gruen zones and femoral configuration according to Dorr. Results: A total of 333 stems in 332 patients (female 191; male 141) met our inclusion criteria. The mean age at surgery was 63 (range 21–87) years. Migration analysis by EBRA-FCA showed a mean subsidence of 1.6 mm at final follow-up at 96 months with a maximum noted mean subsidence of 2.0 mm at 72 and 84 months. Dorr Type A showed a tendency of less subsidence than did Dorr Type B and was statistically significant at 6 (p = 0.0396) and 72 months (p = 0.0127). The body mass index (BMI) and increased subsidence were not found to correlate (p > 0.05). For this cohort, the overall femoral revision-free rate was 95.2% and the revision-free rate for aseptic loosening was 99.1%. Conclusions: The results showed migration behavior in cementless stems with initial increased migration and subsequent secondary stabilization, suggesting an excellent long-term outcome. Stem migration of this tapered proximally anchored stem might be lower in Dorr Type A than in Dorr Type B femurs without being statistically significant at all time points. Full article

(This article belongs to the Special Issue Orthopedic Surgery in Elderly Patients: Past, Present, and Future)

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15 pages, 4540 KiB

Open AccessArticle

Incidence, Risk Factors, and Outcomes of Symptomatic Bone Cement Displacement following Percutaneous Kyphoplasty for Osteoporotic Vertebral Compression Fracture: A Single Center Study

by Junbo Qi, Yuanyu Hu, Zhongwei Yang, Yanlei Dong, Xin Zhang, Guojin Hou, Yang Lv, Yan Guo, Fang Zhou, Bingchuan Liu and Yun Tian

J. Clin. Med. 2022, 11(24), 7530; https://doi.org/10.3390/jcm11247530 - 19 Dec 2022

Cited by 10 | Viewed by 2388

Abstract

Study design: Retrospective. Background: Symptomatic bone cement displacement (BCD) is a rare complication following percutaneous kyphoplasty (PKP) interventions for osteoporotic vertebral compression fracture (OVCF). This study aimed to investigate the incidence and the outcomes of symptomatic BCD comprehensively and identify its risk factors. Methods: The clinical data of patients treated with PKP for OVCF between January 2012 and December 2020 were extracted. Patients who developed BCD following PKP during follow-up were divided into the symptomatic and asymptomatic groups. Patients who did not develop BCD were assigned to the control group. Univariate and multiple logistic regression analyses were used to compare the three clinical groups’ features to assess the independent risk factors for the symptomatic and asymptomatic groups. Results: A total of 896 patients were enrolled. Twenty-one patients (2.3%) were identified as having symptomatic BCD following PKP for OVCF, and 35 (3.9%) developed asymptomatic BCD. Compared with the control group, the symptomatic and asymptomatic groups had a higher incidence of anterior leakage, intravertebral vacuum cleft (IVC) signs, and a lower cement distribution score. The symptomatic group had a lower relative cross-sectional area (rCSA) of the paraspinal muscle (PSM), higher PSM fatty degeneration, and higher kyphotic angle (at the last follow-up) than the asymptomatic and control groups. For outcomes, the symptomatic group had a higher VAS/ODI score and a higher incidence of new vertebral fractures compared with the asymptomatic and control groups. Anterior leakage (OR: 1.737, 95% CI: 1.215–3.300), the IVC sign (OR: 3.361, 95% CI: 1.605–13.036), the cement distribution score (OR: 0.476, 95% CI: 0.225–0.904), PSM rCSA (OR: 0.953, 95% CI: 0.917–0.992), and PSM fatty degeneration (OR: 1.061, 95% CI: 1.005–1.119) were identified as independent risk factors for the symptomatic group. Anterior leakage (OR: 1.839, 95% CI: 1.206–2.803), the IVC sign (OR: 2.936, 95% CI: 1.174–9.018), and cement distribution score (OR: 0.632, 95% CI: 0.295–0.858) were independent risk factors for the asymptomatic group. Conclusion: The incidence of symptomatic BCD is 2.3% in patients treated with PKP. Anterior leakage, the IVC sign, and the distribution score were independent risk factors for BCD, and paraspinal muscle degeneration was a specific risk factor for symptomatic BCD. Symptomatic BCD can lead to poor outcomes. Full article

(This article belongs to the Special Issue Orthopedic Surgery in Elderly Patients: Past, Present, and Future)

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10 pages, 1283 KiB

Open AccessArticle

EBRA Migration Analysis of a Modular, Distally Fixed Stem in Hip Revision Arthroplasty: A Clinical and Radiological Study

by Philipp Blum, David Putzer, Johannes Neugebauer, Markus Neubauer, Markus Süß and Dietmar Dammerer

J. Clin. Med. 2022, 11(19), 5857; https://doi.org/10.3390/jcm11195857 - 3 Oct 2022

Viewed by 1939

Abstract

Background: Massive osteolysis of the proximal femur makes stem revision a challenging procedure. EBRA-FCA provides the opportunity to determine stem migration, which is considered a predictive factor for implant survival. In this study, we aimed to analyze the migration behavior of a modular, distally fixed reconstruction prosthesis. Methods: Applying a retrospective study design, we reviewed all consecutive patients who received a cementless MP reconstruction prosthesis (Waldemar Link GmbH & Co. KG, Hamburg, Germany) at our Department between 2005 and 2019. We reviewed medical histories and performed radiological measurements using EBRA-FCA software. Results: A total of 67 stems in 62 patients (female 26; male 36) fulfilled our inclusion criteria. Mean age at surgery was 68.0 (range 38.7–88.44) years. EBRA migration analysis showed a median subsidence of 1.6 mm (range 0.0–20.6) at 24 months. The angle between stem and femur axis was 0.3° (range 0.0°–2.9°) at final follow-up. No correlation between body mass index and increased subsidence was found (p > 0.05). Overall revision-free rate amounted to 92.5% and revision-free rate for aseptic loosening to 98.5%. Furthermore, no case of material breakage was detected. Conclusions: In summary, the MP reconstruction prosthesis showed low subsidence and reduction in the migration rate over the investigated follow-up. Based on this, the modular stem can be considered as a good therapy option in challenging stem revisions offering various options to address the individual anatomical situation. Full article

(This article belongs to the Special Issue Orthopedic Surgery in Elderly Patients: Past, Present, and Future)

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8 pages, 696 KiB

Open AccessArticle

MRI Assessment of the Early Disc Degeneration Two Levels above Fused Lumbar Spine Segment: A Comparison after Unilateral and Bilateral Transforaminal Lumbar Interbody Fusion (TLIF) Procedure

by Milka Kljaic Dujic, Gregor Recnik, Milko Milcic, Eva Bosnjak and Mitja Rupreht

J. Clin. Med. 2022, 11(14), 3952; https://doi.org/10.3390/jcm11143952 - 7 Jul 2022

Cited by 2 | Viewed by 1679

Abstract

Background: Adjacent segment degeneration (ASD) has become a great concern as a late complication in patients following fusion spine surgery with a potential need for revision surgery. Segments above the fused spine have higher mobility and they are especially prone to accelerated disc degeneration. The purpose of our study is to investigate early disc degenerative changes two levels above a surgically fused lumbar spine segment and to compare MRI analyses after unilateral and bilateral TLIF procedures. Methods: A total of 117 patients were included in this cross-sectional retrospective single center study (after bilateral TLIF surgery: n = 91, and after unilateral TLIF: n = 26). In both groups, the average patient age was similar: 62.84 years (SD = 12.53) in the unilateral TLIF group and 60.67 years (SD = 11.89) in the bilateral TLIF group. On average, MRI was performed 2.5 years after surgery (SD = 2.09). The modified eight-level Pfirrmann grading system was used for the assessment of disc degeneration severity. Descriptive statistics and the Mann–Whitney test were used to show differences in the Pfirrmann grades regarding the after-surgery period and the patient age. The Wilcoxon signed-rank test results were used to display differences in the Pfirrmann grades before and after surgery. Results: The comparison of mean values, regardless of the type of surgery, shows that this mean value is on average higher in the first segment adjacent to the fused spine segment. The assessment of the intervertebral disc structure in BIL TLIF is higher in both the first and the second segment. Early disc degeneration progression is subtle yet detectable (UNI TLIF 9.28% vs. BIL TLIF 16.74%). The assessment of the intervertebral disc structure is on average lower in patients aged less than 50 years at time of surgery compared with patients aged more than 50 years in UNI TLIF, and higher in the BIL TLIF group, for both the first and the second segment. Conclusion: Patients who had undergone unilateral TLIF fusion surgery have a lower rate of early disc degenerative changes. Considering a significantly higher rate of progressive disc degenerative changes in the elderly with bilateral fusion surgery, extra caution is required in the selection of appropriate surgical technique. Full article

(This article belongs to the Special Issue Orthopedic Surgery in Elderly Patients: Past, Present, and Future)

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19 pages, 1476 KiB

Open AccessArticle

Early Reoperation Rates and Its Risk Factors after Instrumented Spinal Fusion Surgery for Degenerative Spinal Disease: A Nationwide Cohort Study of 65,355 Patients

by Jihye Kim, Hwan Ryu and Tae-Hwan Kim

J. Clin. Med. 2022, 11(12), 3338; https://doi.org/10.3390/jcm11123338 - 10 Jun 2022

Cited by 8 | Viewed by 1922

Abstract

Reoperation is a major concern in spinal fusion surgery for degenerative spinal disease. Earlier reported reoperation rates were confined to a specific spinal region without comprehensive analysis, and their prediction models for reoperation were not statistically validated. Our study aimed to present reasonable base rates for reoperation according to all possible risk factors and build a validated prediction model for early reoperation. In our nationwide population-based cohort study, data between 2014 and 2016 were obtained from the Korean National Health Insurance claims database. Patients older than 19 years who underwent instrumented spinal fusion surgery for degenerative spinal diseases were included. The patients were divided into cases (patients who underwent reoperation) and controls (patients who did not undergo reoperation), and risk factors for reoperation were determined by multivariable analysis. The estimates of all statistical models were internally validated using bootstrap samples, and sensitivity analyses were additionally performed to validate the estimates by comparing the two prediction models (models for 1st-year and 3rd-year reoperation). The study included 65,355 patients: 2939 (4.5%) who underwent reoperation within 3 years after the index surgery and 62,146 controls. Reoperation rates were significantly different according to the type of surgical approach and the spinal region. The third-year reoperation rates were 5.3% in the combined lumbar approach, 5.2% in the posterior lumbar approach, 5.0% in the anterior lumbar approach, 3.0% in the posterior thoracic approach, 2.8% in the posterior cervical approach, 2.6% in the anterior cervical approach, and 1.6% in the combined cervical approach. Multivariable analysis identified older age, male sex, hospital type, comorbidities, allogeneic transfusion, longer use of steroids, cages, and types of surgical approaches as risk factors for reoperation. Clinicians can conduct comprehensive risk assessment of early reoperation in patients who will undergo instrumented spinal fusion surgery for degenerative spinal disease using this model. Full article

(This article belongs to the Special Issue Orthopedic Surgery in Elderly Patients: Past, Present, and Future)

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9 pages, 637 KiB

Open AccessArticle

Short- and Mid-Term Survival of Geriatric Patients with Septic Arthritis of the Knee and the Impact of Risk Factors on Survival

by Nina Pauline Haag, Markus Geßlein, Michael Millrose, Renate Ziegler, Maximilian Willauschus, Jörg Steinmann, Hermann Josef Bail and Johannes Rüther

J. Clin. Med. 2022, 11(3), 755; https://doi.org/10.3390/jcm11030755 - 30 Jan 2022

Cited by 4 | Viewed by 2473

Abstract

Septic arthritis is common in older adults and can be related to joint surgery or hematogenous distribution. To date, the risk factors affecting survival are unknown. This study aimed to evaluate the effects of existing implants, positive synovial microbiological culture results, and the American Society of Anesthesiology Physical Status (ASA) classification on the short- and mid-term survival of older patients with primary septic gonarthritis. This retrospective study included 133 older adults >60 years who underwent surgery for primary septic gonarthritis. Data were collected from medical records and public obituaries. Kaplan–Meier survival curves were used to estimate the probability of survival, as well as log-rank tests to measure and compare survival rates over one- and five-year periods. The mean age was 74.9 years (SD ± 9.2), and the 5-year follow-up rate was 74.3% (the mean follow-up was 3000.5 days; SD ± 1771.6). Mean survival was significantly different in patients with implants and without implants (p = 0.015), and between ASA II, ASA III, and ASA IV (p < 0.001). There was no significant difference in the survival of patients with or without a positive synovial microbiological culture (p = 0.08). Older adults with septic monoarthritis and pre-existing medical implants showed impaired survival. The ASA classification prior to surgery for primary septic monoarthritis can be helpful in identifying patients with poorer mid-term outcomes. Full article

(This article belongs to the Special Issue Orthopedic Surgery in Elderly Patients: Past, Present, and Future)

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9 pages, 440 KiB

Open AccessArticle

Increased Geriatric Treatment Frequency Improves Mobility and Secondary Fracture Prevention in Older Adult Hip Fracture Patients—An Observational Cohort Study of 23,828 Patients from the Registry for Geriatric Trauma (ATR-DGU)

by Johannes Gleich, Evi Fleischhacker, Katherine Rascher, Thomas Friess, Christian Kammerlander, Wolfgang Böcker, Benjamin Bücking, Ulrich Liener, Michael Drey, Christine Höfer and Carl Neuerburg

J. Clin. Med. 2021, 10(23), 5489; https://doi.org/10.3390/jcm10235489 - 23 Nov 2021

Cited by 5 | Viewed by 2248

Abstract

Interdisciplinary orthogeriatric care of older adult hip fracture patients is of growing importance due to an ageing population, yet there is ongoing disagreement about the most effective model of care. This study aimed to compare different forms of orthogeriatric treatment, with focus on their impact on postoperative mobilization, mobility and secondary fracture prevention. In this observational cohort study, patients aged 70 years and older with a proximal femur fracture requiring surgery, were included from 1 January 2016 to 31 December 2019. Data were recorded from hospital stay to 120-day follow-up in the Registry for Geriatric Trauma (ATR-DGU), a specific designed registry for older adult hip fracture patients. Of 23,828 included patients from 95 different hospitals, 72% were female, median age was 85 (IQR 80–89) years. Increased involvement of geriatricians had a significant impact on mobilization on the first day (OR 1.1, CI 1.1–1.2) and mobility seven days after surgery (OR 1.1, CI 1.1–1.2), initiation of an osteoporosis treatment during in-hospital stay (OR 2.5, CI 2.4–2.7) and of an early complex geriatric rehabilitation treatment (OR 1.3, CI 1.2–1.4). These findings were persistent after 120 days of follow-up. Interdisciplinary treatment of orthogeriatric patients is beneficial and especially during in-patient stay increased involvement of geriatricians is decisive for early mobilization, mobility and initiation of osteoporosis treatment. Standardized treatment pathways in certified geriatric trauma departments with structured data collection in specific registries improve outcome monitoring and interpretation. Full article

(This article belongs to the Special Issue Orthopedic Surgery in Elderly Patients: Past, Present, and Future)

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Review

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10 pages, 1491 KiB

Open AccessReview

Motorized Intramedullary Nail Lengthening in the Older Population

by Kenneth P. Powell, Ahmed I. Hammouda, Larysa P. Hlukha, Jessica C. Rivera, Minoo Patel, S. Robert Rozbruch, Janet D. Conway and John E. Herzenberg

J. Clin. Med. 2022, 11(17), 5242; https://doi.org/10.3390/jcm11175242 - 5 Sep 2022

Cited by 5 | Viewed by 2488

Abstract

Limb lengthening has not been widely employed in the elderly population due to concerns that outcomes will be inferior. The purpose of this multicenter, retrospective case-control series was to report the bone healing outcomes and complications of lower limb lengthening in older patients (≥60 years) using magnetic intramedullary lengthening nail (MILN). Our hypothesis was that healing parameters including consolidation days, the consolidation index, maturation days, and the maturation index, as well as the number of adverse events reported in the older population, would be no different to those of the general adult population. We retrospectively reviewed charts and radiographs from patients ≥60 years of age with limb-length discrepancies who underwent femoral or tibial lengthening using a MILN. Parameters were compared among the age categories “≤19 years,” “20–39 years,” “40–59 years,” or “≥60 years” and propensity-matched cohorts for the age groups 20–59 years and ≥60 years. Complications were reported as percentages for each age category. In the study period, 354 MILN were placed in 257 patients. Sixteen nails were placed in patients 60 years of age or older (mean 65 ± 5 years; range 60–72 years). Comparisons of healing parameters showed no difference between those aged 60+ and the younger cohort. Complication percentages were not statistically significant (p = 0.816). Limb lengthening with MILN may therefore be considered a safe and feasible option for a generally healthy elderly population. Full article

(This article belongs to the Special Issue Orthopedic Surgery in Elderly Patients: Past, Present, and Future)

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