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The Effect of Age on Pain, Function, and Quality of Life After Total Hip and Knee Arthroplasty
C. Allyson Jones, PhD;
Donald C. Voaklander, PhD;
D. William C. Johnston, MD;
Maria E. Suarez-Almazor, MD, PhD
Arch Intern Med. 2001;161:454-460.
ABSTRACT
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Background As utilization rates for total joint arthroplasty increase, there is
a hesitancy to perform this surgery on very old patients. The objective of
this prospective study was to compare pain, functional, and health-related
quality-of-life outcomes after total hip and total knee arthroplasty in an
older patient group ( 80 years) and a representative younger patient group
(55-79 years).
Methods In an inception community-based cohort within a Canadian health care
system, 454 patients who received primary total hip arthroplasty (n = 197)
or total knee arthroplasty (n = 257) were evaluated within a month prior to
surgery and 6 months postoperatively. Pain, function, and health-related quality
of life were evaluated with the Western Ontario and McMaster Universities
(WOMAC) Osteoarthritis Index and the 36-Item Short-Form Health Survey (SF-36).
Results There were no age-related differences in joint pain, function, or quality-of-life
measures preoperatively or 6 months postoperatively. Furthermore, after adjusting
for potential confounding effects, age was not a significant determinant of
pain or function. Although those in the older and younger groups had comparable
numbers of comorbid conditions and complications, those in the older group
were more likely to be transferred to a rehabilitation facility than younger
patients. Regardless of age, patients did not achieve comparable overall physical
health when matched with the general population for age and sex.
Conclusions With increasing life expectancy and elective surgery improving quality
of life, age alone is not a factor that affects the outcome of joint arthroplasty
and should not be a limiting factor when considering who should receive this
surgery.
INTRODUCTION
UTILIZATION rates for both total hip and total knee arthroplasties (THA/TKA)
have been steadily increasing.1, 2
While the majority of patients receiving joint arthroplasties are elderly,
the question of who should receive joint arthroplasty is a function of age.1 The average age for joint replacements has not increased,
in spite of an aging population and prosthetic advances.1, 3
In a cohort study of US Medicare beneficiaries, patients aged 85 years or
older were less likely to receive TKA than their younger counterparts.1 Moreover, older patients are as willing to undergo
joint arthroplasty as younger patients.4 Hesitancy
to perform this surgery in older patient populations is speculative and may
not be related to age itself, but rather may be associated with comorbid conditions
and postoperative complications.
Small clinical studies have reported limited evidence of favorable pain
and functional outcomes of joint arthroplasty in patients aged 80 years or
older, but also higher rates of complication and mortality.5, 6, 7, 8, 9, 10
The generalizability of these findings is restricted because of the descriptive
or retrospective nature of the study designs used. Findings from comparative
studies11, 12, 13 concurred
that patients aged 80 years or older who received joint arthroplasty attained
pain and functional levels similar to those of younger patients (65-79 years)
over a 1- to 2-year follow-up. In contrast to previous descriptive studies,
the case-control studies that examined complications did not report a higher
complication rate in older age groups.11, 12
In light of the limited evidence, much clinical controversy exists with
respect to age and the risk of surgery when considering joint arthroplasties.
Therefore, referring physicians, rheumatologists, and surgeons are confronted
with weighing the risks and benefits of joint arthroplasties for older patients.
While the benefits and risks of joint arthroplasty have primarily been described
in small clinical study groups of highly selected patients, no study has prospectively
compared these outcomes in a community-based study group of older and younger
patients. Because utilization rates continue to increase and secondary factors
affecting surgery are unclear, the effect of age needs to be evaluated in
these patients. This is the first prospective community-based study comparing
pain, function, and health-related quality-of-life outcomes after total joint
arthroplasty in patients 80 years or older and a younger group.
The primary purpose of this study was to prospectively compare pain,
functional, and health-related quality-of-life outcomes after THA and TKA
in an older patient group (80 years) and a representative younger patient
group (55-79 years) receiving joint arthroplasties.
PATIENTS AND METHODS
PATIENTS
A prospective community-based cohort study of patients recommended for
either primary THA or TKA was conducted within a Canadian universal health
care region (Edmonton, Alberta). This was an inception cohort that had been
assembled for another study examining waiting-list times.14
A consecutive cohort of patients placed on the waiting list from December
18, 1995, through January 24, 1997, for elective THA or TKA was identified.
Selection criteria identified patients (1) who were scheduled for primary
THA or TKA, (2) who were placed on the health region's joint-replacement waiting
list for at least 7 days before their surgery, (3) who resided within the
health care region, (4) who were 55 years or older, and (5) who spoke English.
Surgical procedures excluded from this study were hemiarthroplasties, revisions,
and emergency arthroplasties. Participants who resided in long-term care institutions
also were excluded.
In this study, 558 patients were eligible for participation. Among this
patient group, 78 patients did not participate, either because they received
surgery prior to the baseline interview or because they refused (n = 71).
Another 26 patients were lost to follow-up. The final study cohort consisted
of 454 patients, of whom 197 and 257 received THA and TKA, respectively. Analysis
of nonresponses revealed no demographic differences between the final study
cohort and those patients who did not participate with respect to age (P = .91), sex (P = .78), or type
of joint replaced (P = .46).
No bilateral joint surgical procedures were performed during this study
period. All 26 orthopedic surgeons who were practicing at either of the 2
hospitals within the health care region participated in the study. An equal
proportion of operations was performed at each hospital. Treatment was ensured
by standardized care maps for THA and TKA within the acute care, home care,
and community rehabilitation settings. The study protocol was reviewed and
approved by the University of Alberta Health Research Ethics Board.
STUDY PROTOCOL
When patients' names appeared on the regional joint replacement waiting
list, they were contacted to participate in the study. Upon agreement, in-person
interviews were arranged. Patients were informed that they could withdraw
from the study at any time without affecting their medical care. Preoperative
interviews were completed within 31 days prior to surgery, and follow-up interviews
were performed 6 months after surgery. Assessments were completed by 1 of
3 health professionals (2 nurses and a physical therapist) who were not involved
in care of the participants. During these interviews, information regarding
pain, function, health-related quality of life, sociodemographic characteristics,
and medical status was gathered.
MEASURES
Joint-specific pain and functional outcomes were evaluated with a self-administered
health questionnaire, the Western Ontario and McMaster Universities (WOMAC)
Osteoarthritis Index.15, 16 Each
item is scored using a 5-point Likert scale, and aggregate scores for joint-specific
pain (5 items), physical function (17 items), and stiffness (2 items) are
calculated. While the use of an overall score is not recommended, each subscale
score was transformed to a range from 0 to 100 points, with a score of 100
indicating no pain, dysfunction, or stiffness.17
The WOMAC is a responsive, reliable, and valid instrument and has been extensively
used to measure disability of the osteoarthritic hip and knee.15, 18
Health-related quality-of-life domains were measured using the 36-Item
Short-Form Health Survey (SF-36).19, 20, 21
This generic health measure is a self-administered 36-item questionnaire comprising
8 health dimensions: bodily pain, physical function, role limitations related
to physical health (physical role function), mental health, role limitations
related to emotional health (emotional role function), social functioning,
vitality, and general health, as well as 2 summary measures: physical component
summary and mental component summary. No global score exists for the SF-36.
Scoring for the 8 dimensions ranges from 0 to 100 points, with higher scores
representing better health. Reliability and validity have been extensively
evaluated in a variety of patient populations, including patients undergoing
THA and TKA and elderly persons both residing in the community and undergoing
elective surgery.17, 20, 22, 23, 24, 25, 26
Sociodemographic and medical information, including age, sex, education,
previous joint arthroplasty, and living arrangements, was collected at the
baseline interview. The number of self-reported chronic conditions was recorded
at the baseline interview using a list of 23 items27
and presented as a simple additive score.28
Data regarding the type of implant fixation (cemented, hybrid, or cementless),
the number and type of in-hospital complications (wound infection, dislocation,
manipulation under anesthesia, cardiorespiratory involvement, peripheral/central
nervous system involvement, urinary tract infection, acute confusion, or blood
loss requiring transfusion after surgery), and other medical information,
such as diagnosis, were extracted from patients' medical records by 2 health
professionals. Health services utilization data were extracted from the regional
database.
STATISTICAL ANALYSES
Because pain and functional outcomes are different for THA and TKA,29, 30, 31 the data were analyzed
with respect to the type of joint replaced. Effect sizes were calculated for
the WOMAC and SF-36 scores so that comparisons could be made between the age
groups. This method standardizes scores for each age group, dividing the difference
between the preoperative score and the score at the 6-month follow-up by the
SD of the preoperative score. An effect size of 1.0 indicates a change of
1 baseline SD.
The preoperative and 6-month mean ± SD values of the SF-36 were
compared with age- and sex-adjusted normative values (55-64 vs 65 years)
using t tests. Because the SF-36 does not have a
specific category for 80 years and above, the published normative values for
age 65 years and above were weighted with respect to the sex distribution
of the older study group. An overall age- and sex-adjusted normative value
for each dimension and component summary score was then calculated based on
the age and sex distribution of the 2 age groups for each joint. Only normative
values for the SF-36 were used, since the WOMAC does not have normative values.
Bivariate analyses, such as the  2 statistic, were performed before multivariate analyses. Stepwise multiple
linear regression analyses were used to evaluate the effect of age on pain
and function while controlling for possible confounding effects of other variables.
Models for changes in pain and function as measured by the WOMAC are presented
for each joint. The selection of independent variables in the final models
was based on their clinical significance or bivariate association with the
dependent variables. Age, sex, waiting time, and length of stay in the acute
care hospital were force-entered into the pain and functional models. Variables
considered predictive of pain included preoperative bodily pain (SF-36), the
number of comorbid conditions, and implant fixation. Preoperative joint pain
(WOMAC), physical function (SF-36), body mass index, the number of comorbid
conditions, preoperative living arrangements, and contralateral joint involvement
were entered using forward selection as variables predictive of function.
Age was treated as a continuous variable in the final model, but was also
examined as a dichotomous variable. A subgroup analysis of patients 85 years
or older did not show any deviations from outcomes of patients 80 years or
older; therefore, and older age group included those patients 80 years or
older.
Statistical analyses were performed using SPSS software version 8.0
(SPSS Inc, Chicago, Ill). All statistical testing was performed using 2-tailed
tests, with significance at P .05.
RESULTS
Among the 197 participants who received THA, 163 (83%) were between
55 and 79 years of age and 34 (17%) were 80 years or older. Of the 257 participants
who received TKA, 222 (86%) were between 55 and 79 years, and 35 (14%) were
80 years or older. Three deaths occurred within the TKA group during the 6-month
follow-up. Two patients from the younger group died of pulmonary emboli within
1 month of discharge. The third death occurred in the older group 3 months
after surgery and was unrelated to the operation. Demographic and baseline
data are summarized in Table 1.
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Table 1. Characteristics of Participants*
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MEDICAL STATUS
Within both age groups, the majority of patients had at least one comorbid
condition. The mean number of comorbid conditions was similar for both age
groups regardless of the joint replaced (P>.05) (Table 1). The most frequently cited problem
for patients with hip involvement was lower back pain, regardless of age (63
patients [39%] in the younger group and 15 patients [44%] in the older group).
Hypertension was the most common comorbid condition in the TKA group, occurring
in approximately 40% of the patients in each age group (90 of 222 in the younger
group and 14 of 35 in the older group). Eye problem was the second most cited
condition among the older patients in both the THA (n = 13 [38%]) and TKA
(n = 11 [31%]) groups.
HEALTH SERVICES UTILIZATION
The average waiting time for surgery ranged from 74 to 108 days and
was not age dependent for TKA. There was a trend toward statistical significance
for older patients with THA waiting less than younger patients (mean ±
SD, 74 ± 61 vs 103 ± 85 days; P = .06).
Using multiple regression and adjusting for covariates of age, sex, and length
of stay within the hospital, waiting time did not affect pain or function
at 6 months.
While no clinically significant differences were observed with the length
of stay in the acute care setting, patients in the older age group were more
likely to be transferred to rehabilitation facilities regardless of the type
of joint replaced: 71% (n = 24) in the THA group and 83% (n = 29) in the TKA
group. Only 40% of those in the younger group were transferred to other facilities
for further rehabilitation. Those patients who were transferred to rehabilitation
facilities had similar lengths of stay in the rehabilitation facilities regardless
of age group (P>.05) (Table 1). At the 6-month follow-up interview, all patients had returned
to the community. Within 6 months of discharge, 12 patients were admitted
to the emergency department for prosthetic reasons, such as hip dislocations
(n = 4), infections (n = 4), mechanical complications of prosthetic device
(n = 3), and deep vein thrombosis (n = 1). Of these 12 patients, 2 who were
80 years or older were seen for hip dislocation; all other patients were from
the younger groups (THA, n = 6; TKA, n = 4).
SURGICAL FACTORS
While the majority of patients had no in-hospital complications, the
incidence of in-hospital complications was 0.39 complications per patient
for the younger group regardless of the joint replaced (Table 1). Among the older patients in the THA and TKA groups, these
rates were 0.55 and 0.41, respectively. These differences were not significant
(P>.05).
OUTCOMES
WOMAC Outcomes
Patients, regardless of age, showed significant improvement in pain,
function, and stiffness (Table 2).
Moreover, the preoperative and 6-month postoperative scores were similar between
the 2 age groups, although the older group reported less hip stiffness at
6 months. The magnitude of change as depicted by effect sizes typically showed
greater gains in pain than function or stiffness for both age groups (Table 3).
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Table 2. Western Ontario McMaster Universities (WOMAC) Osteoarthritis
Index Scores by Age Group*
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Table 3. Effect Sizes* for WOMAC and SF-36 Scores by Age Group
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Health-Related Quality of Life (SF-36)
Both age groups showed large effect sizes for bodily pain and physical
function. Effect sizes were smaller for health, mental health, and role limitation
due to emotional function dimensions (Table
3). Table 4 depicts
improvements reported in all of the SF-36 dimensions for the younger group
(P<.001). The older group did not improve in health,
mental health, and role limitation due to emotional function dimensions (P>.05); however, these values were comparable with age-
and sex-adjusted values for the general population. Both age groups reached
normative values in similar dimensions; that is, smaller changes were typically
reported for the mental health dimensions, but these values were within the
range of values for the general population. Changes were greater for physical
health dimensions (bodily pain and physical function), but did not reach normative
values.
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Table 4. 36-Item Short-Form Health Survey (SF-36) Scores by Age Group*
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Multiple Linear Regression Analyses
Age did not have a strong linear relationship with either pain or function.
When age was entered into multiple linear regression models while controlling
for the effect of other variables, it again was not a significant variable
(Table 5 and Table 6). Age was examined both as a dichotomous and continuous
variable. Inasmuch as age was not significant, the variables entered into
the analyses accounted for 26% (THA) and 18% (TKA) of the explained variance
in pain and 38% (THA) and 28% (TKA) of the explained variance in function.
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Table 5. Multiple Linear Regression Model for Change in Pain*
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Table 6. Multiple Linear Regression Model for Change in Function*
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COMMENT
In this prospective cohort study of THA and TKA, patients 80 years or
older reported significant pain relief and functional improvement as well
as positive gains in health-related quality of life that were comparable with
those of patients aged 55 to 79 years. Our findings are consistent with previous
improvements reported in younger cohorts from other studies.32, 33, 34
Patients with THA reported a 38% to 46% improvement in pain and function,
while patients with TKA reported less of a change, a 28% to 34% improvement
regardless of age. Although receiving a total joint arthroplasty is a function
of age,1, 2 this study found that
joint-specific pain and functional outcomes achieved were not age dependent.
Upon further review of the regression models, if age had been significant,
it would have had a small effect on the change in pain and function because
of the small regression coefficient.
Unlike other studies, this is the first prospective community-based
study to compare pain, function, and health-related quality-of-life outcomes
after total joint arthroplasties in patients 80 years or older and a younger
group. These findings are presumed to be representative of general practice
patterns since this cohort was not restricted to one center or surgeon and
was conducted within a universal health care system. Although this cohort
was community based, the older patient group may be considered as a healthy
cohort since these patients had numbers of comorbid conditions and complication
rates similar to those of their younger counterparts. This may have been because
of preferential bias in referral within the general practice for "suitable"
candidates for this surgery; that is, frail elderly patients were not referred
for surgery. This observation is supported by findings from studies that have
recognized barriers to patients receiving arthroplasties1, 4;
however, it was unclear whether the bias for surgery occurred at the primary
or orthopedic care level.3, 35
Others have questioned the wisdom of performing elective surgery in
octogenarian patients because of their presumed susceptibility to major complications
in the early postoperative phase.5, 6
Our findings did not show a higher rate of complications in the older patients.
Moreover, these results concur with other findings reported in a similar patient
study group.11 While the complication rates
were comparable in the older and younger groups, the most frequently cited
complications, urinary tract infection and deep vein thrombosis, were not
considered major complications. Overall, the 6-month mortality rate was low
in this study cohort; there were 2 fatal pulmonary embolisms in the younger
group.
Although the older and younger patients had a similar number of comorbid
conditions and comparable complication rates, a greater proportion of older
patients were transferred to rehabilitation facilities rather than being discharged
directly home. Other studies have reported that older age, living alone, and
an increased number of comorbid conditions are determinants of receiving inpatient
rehabilitation services before returning home.36
In this study cohort, a greater proportion of the older patients lived alone,
yet all patients resided in the community at the 6-month follow-up. Although
pain and functional gains were not age dependent, older patients were more
likely to receive subsequent inpatient rehabilitation.
In conclusion, those patients 80 years or older attained pain, functional,
and health-related quality-of-life outcomes expected for their age similar
to those of a representative younger group (55-79 years) who received joint
arthroplasties. Older patients were more likely to live alone and to be transferred
to a rehabilitation facility; however, the number of comorbid conditions and
in-hospital complication rates were comparable with those of the younger group.
Furthermore, all older patients resided in the community at the 6-month follow-up.
For the healthy person who is 80 years or older, joint arthroplasty provides
pain relief and functional improvement, comparable with benefits in the younger
patient population, and this is also reflected in similar health-related quality-of-life
gains. With increasing life expectancy and elective surgery improving the
quality of life, age alone is not a factor that affects the outcome of total
joint arthroplasty and should not be a limiting factor when deciding who should
receive this surgery.
AUTHOR INFORMATION
Accepted for publication August 1, 2000.
This study was funded in part by grants from the Capital Health Authority
Research and Grant Fund, Edmonton, Alberta, and the Edmonton Orthopaedic Research
Trust. Dr Jones received support from the Canadian Physiotherapy Foundation,
Toronto, Ontario, the Royal Canadian Legion, Toronto, and the Alberta Heritage
Foundation for Medical Research, Edmonton. Dr Suarez-Almazor received support
from the Arthritis Society of Canada, Toronto, and the Alberta Heritage Foundation
for Medical Research.
The authors thank Karen Kelly, PhD, Sue Barrett, BN, Lynn Redfern, PhD,
and Gordon Kramer, MHSA, for their assistance with this study.
From the Department of Public Health Sciences, University of Alberta,
Edmonton (Drs Jones and Voaklander); Division of Orthopaedic Surgery, Department
of Surgery, University of Alberta Hospital, Edmonton (Dr Johnston); Section
of Health Services Research, Department of Medicine, Baylor College of Medicine,
Houston, Tex (Dr Suarez-Almazor).
Corresponding author and reprints: C. Allyson Jones, PhD, PT, Room
2137, Dentistry/Pharmacy Bldg, University of Alberta, Edmonton, Alberta, Canada
T6G 2N8 (e-mail: ajones{at}pharmacy.ualberta.ca).
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Response Shift in Outcome Assessment in Patients Undergoing Total Knee Arthroplasty
Razmjou et al.
JBJS 2006;88:2590-2595.
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Differences in the views of orthopaedic surgeons and referring practitioners on the determinants of outcome after total hip replacement
Sturmer et al.
J Bone Joint Surg Br 2005;87-B:1416-1419.
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The Functional Outcomes of Total Knee Arthroplasty
Kane et al.
JBJS 2005;87:1719-1724.
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Health-Related Quality of Life in Total Hip and Total Knee Arthroplasty. A Qualitative and Systematic Review of the Literature
Ethgen et al.
JBJS 2004;86:963-974.
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Response Bias: Effect on Outcomes Evaluation by Mail Surveys After Total Knee Arthroplasty
Kim et al.
JBJS 2004;86:15-21.
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Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study
Nilsdotter et al.
Ann Rheum Dis 2003;62:923-930.
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Elective Primary Total Hip Arthroplasty in Octogenarians
Wurtz et al.
Journals of Gerontology Series A: Biological Sciences and Medical Sciences 2003;58:M468-471.
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Orthopedic Surgery: A New Frontier
O'Brien
Mayo Clin Proc. 2003;78:275-277.
The Clinical Importance of Meniscal Tears Demonstrated by Magnetic Resonance Imaging in Osteoarthritis of the Knee
Bhattacharyya et al.
JBJS 2003;85:4-9.
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Age and waiting time as predictors of outcome after total hip replacement for osteoarthritis
Nilsdotter and Lohmander
Rheumatology (Oxford) 2002;41:1261-1267.
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What's New in Orthopaedic Rehabilitation
Botte et al.
JBJS 2001;83:1920-1926.
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