Thirty-day morbidity and mortality following primary total elbow arthroplasty in octogenarians

Abstract

Background

Octogenarians are at an increased risk of morbidity and mortality following various orthopaedic procedures, but this has not been explored among total elbow arthroplasty (TEA) patients. Thus, this study analyzed whether octogenarians undergoing TEA are at an increased risk of postoperative complications relative to the younger geriatric population.

Methods

A national database was queried to identify TEA patients. Patients were stratified into an aged 65 to 79 cohort and an aged 80 to 89 cohort. Demographics, comorbidities, and complications were assessed, with the use of bivariate and multivariate analyzes.

Results

In total, 390 patients underwent TEA, with 289 (74.1%) between the ages of 65 to 79 and 101 (25.9%) between the ages of 80 to 89. On bivariate analyzes, patients aged 80 to 89 were more likely to undergo postoperative transfusion (p = 0.001) compared to those aged 65 to 79. Following adjustment on multivariate analyzes, the aged 80 to 89 cohort no longer had an increased risk of postoperative transfusion. There were no differences in mortality, readmission, and reoperation between the two groups.

Discussion

Age greater than 80 should not be used as an independent factor when evaluating whether a geriatric patient is an appropriate candidate for TEA.

Keywords

total elbow arthroplasty octogenarians geriatrics complications

Introduction

The geriatric population (ages 65 and older) is expected to rise rapidly, with a projection of nearly 95 million geriatric Americans by the year 2060 and a consequent increase in the proportion of the total population from 16 percent in 2018 to 23 percent in 2060. With similar population trends globally, the expected amounts of arthroplasty and other orthopaedic procedures being performed among the geriatric population is predicted to increase significantly. For example, Yan et al. found that the number of patients over 80 years undergoing total knee arthroplasty (TKA) increased over a period of 10 years.¹ These geriatric patients carry a significant burden of comorbidities that increases their post-operative surgical risks. Many studies have been conducted to better understand these risks.^2–7 However, these studies grouped all patients over the age of 65 as one cohort and failed to consider the physiological and functional changes that occur with age.^2–7 For example, Johnson et al. showed that octogenarians undergoing cardiac surgery have more comorbidities than patients younger than eighty.⁸ Thus, it is important to elucidate whether any differences in surgical risk exist between octogenarians (ages 80 to 89) and their younger geriatric counterparts (ages 65 to 79).

Several studies have found significant differences in surgical risks between octogenarians and their younger geriatric counterparts for orthopaedic and non-orthopaedic surgeries.^9–12 In patients undergoing major elective gynecologic surgery, the percentage of octogenarians requiring hospitalization for more than one week was significantly higher than the younger geriatric patients (ages 50 to 79).¹² In patients undergoing thyroid surgery, octogenarians were found to have a significantly higher complication rate (24%) compared to a younger cohort (9%) (ages 18 to 79).¹¹ Similar findings are also notable in orthopaedic surgeries. Bovonratwet et al. found that among patients undergoing primary total shoulder arthroplasty (TSA), octogenarians had significantly higher rates of readmission, pneumonia, and urinary tract infection compared to those of ages 70 to 79 years.¹⁰ Similarly, among patients discharged the same day following primary TKA, octogenarians had a higher risk of 30-day readmission and non-home discharge compared to those under age 80.⁹

As highlighted from these previously mentioned studies, differences in risk for post-operative complications may be seen between octogenarians and their younger geriatric counterparts. Therefore, it is essential to explore any possible risk differences across all orthopaedic procedures. However, whether any differences in risk exist between octogenarians and their younger geriatric counterparts undergoing total elbow arthroplasty (TEA) has not yet been explored. Thus, the purpose of this study is to compare thirty-day post-operative complications, readmission, and mortality rates between octogenarians (ages 80 to 89) and younger geriatric patients (ages 65 to 79) undergoing TEA.

Materials and methods

This was a retrospective study performed using data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. The study period was from the years 2006 to 2019. NSQIP is national database that collects surgical information from more than 700 participating institutions. All of the information in this database is deidentified. Data is recorded for preoperative, intraoperative, and postoperative variables. Postoperative variables include complications up to 30 days following the surgical procedure. complications for patients undergoing surgical procedures.^13,14 Previous studies have shown a low disagreement rate when this database was audited.¹⁵ NSQIP has been used in the surgical field to track the preoperative data and postoperative outcomes of individual patients.^16,17

Patient selection

Patients who underwent TEA were identified using Current Procedural Terminology code 24363. In this study, patients were excluded if their age was less than 65. Consequently, two patient cohorts were defined: patients aged 65 to 79 years old and patients aged 80 to 89 years old.

Baseline patient characteristics

For baseline demographics and clinical characteristics of the study population, the following variables were recorded: age, sex, race, body mass index (BMI), and American Society of Anesthesiologists (ASA) classification. The following medical comorbidities and intraoperative variables were collected: congestive heart failure (CHF), hypertension, dialysis, chronic obstructive pulmonary disease (COPD), weight loss in the past 6 months, bleeding disorder, preoperative transfusion, smoker, chronic steroid usage, dependent functional status, diabetes mellitus status, dyspnea, and the type of anesthesia used during the surgery.

Postoperative outcomes

The thirty-day outcomes studied following TEA included superficial surgical site infections, deep surgical site infections, organ space infections, wound dehiscence, pneumonia, pulmonary embolism, reintubation, urinary tract infection, stroke, postoperative transfusion, deep vein thrombosis, myocardial infarction, extended length of stay, readmission, reoperation, and death. Extended length of stay was defined as more than 8 days, or one standard deviation above the mean length of stay for the patients in this study.

Statistical analysis

Chi-squared tests and one-way analysis of variance were utilized where appropriate to compare the baseline demographic and comorbidity differences between the two cohorts. Significant variables were included in the multivariate analysis for p-values < 0.20 to control for covariates.¹⁸ Postoperative outcomes with a p-value < 0.05 were also selected for multivariate analyzes, with the results being reported as odds ratios with 95% confidence intervals. For all statistical tests, a p-value of < 0.05 was considered significant. Statistical Package for the Social Sciences (SPSS; Version 26; Armonk, NY) software was used in this study.

Results

Demographics and comorbidities

In total, 390 patients who underwent TEA were included for analysis. Of these patients, 289 (74.1%) were between ages 65 to 79 and 101 (25.9%) were between ages 80 to 89. Compared to patients aged 65 to 79, those who were aged 80 to 89 were more likely to have a lower BMI (p = 0.047) (Table 1). Relative to patients who were aged 65 to 79, those who were 80 to 89 years old were more likely to have medical comorbidities, including hypertension (p = 0.001), bleeding disorders (p = 0.001), and partially dependent functional status (p = 0.002). On the other hand, patients who were 65 to 79 years old were more likely to be smokers (p = 0.019) and use steroids (p = 0.016) (Table 2).

Table 1.

Total elbow arthroplasty patients’ baseline demographics and clinical characteristics .

Demographics	65-79 years old (N = 289)	80-89 years old (N = 101)	P-value
Age^a (years)	71.10 ± 4.17	83.07 ± 2.71	< 0.001*
Sex^b			0.389**
Male	57 (19.7)	16 (15.8)
Female	232 (80.3)	85 (84.2)
Race^b			0.478**
White	199 (78.3)	66 (76.7)
Black	13 (5.1)	3 (3.5)
Hispanic	29 (11.4)	15 (17.4)
American Indian	4 (1.6)	1 (1.2)
Asian	9 (3.5)	1 (1.2)
BMI^a (kg/m²)	29.34 ± 6.55	27.86 ± 5.75	0.047*
ASA classification^b			0.224**
ASA I	5 (1.7)	0 (0.0)
ASA II	86 (29.8)	23 (22.8)
ASA III	185 (64.0)	71 (70.3)
ASA IV	13 (4.5)	7 (6.9)

BMI: body mass index; ASA: American Society of Anesthesiologists.

The values represent the mean and the standard deviation.

The values represent the number of patients, with the percentage indicated in parentheses.

*Analysis of variance.

**Pearson's chi-squared test.

Bolding equals significance p < 0.05.

Table 2.

Total elbow arthroplasty patients’ baseline comorbidities.

Comorbidities^a	65-79 years old (N = 289)	80-89 years old (N = 101)	P-value*
CHF	6 (2.1)	1 (1.0)	0.479
Hypertension	177 (61.2)	81 (80.2)	0.001
Dialysis	1 (0.3)	1 (1.0)	0.435
COPD	20 (6.9)	7 (6.9)	0.997
Weight loss	1 (0.3)	1 (1.0)	0.435
Bleeding disorder	8 (2.8)	11 (10.9)	0.001
Preoperative transfusion	1 (0.3)	1 (1.0)	0.435
Smoker	26 (9.0)	2 (2.0)	0.019
Steroid use	52 (18.0)	8 (7.9)	0.016
Functional status			0.002
Partially dependent	22 (7.6)	16 (16.2)
Totally dependent	0 (0.0)	2 (2.0)
DM status			0.365
Noninsulin-dependent DM	30 (10.4)	15 (14.9)
Insulin-dependent DM	25 (8.7)	6 (5.9)
Dyspnea			0.238
Moderate exertion	17 (5.9)	6 (5.9)
At rest	0 (0.0)	1 (1.0)
Anesthesia type			0.287
General	278 (96.2)	95 (94.1)
Regional	6 (2.1)	5 (5.0)
MAC	5 (1.7)	1 (1.0)

CHF: congestive heart failure; COPD: chronic obstructive pulmonary disease; DM: diabetes mellitus; MAC: monitored anesthetic care.

*Pearson's chi-squared test.

The values represent the number of patients, with the percentage indicated in parentheses.

Bolding equals significance p < 0.05.

Complications

Following TEA, on bivariate analysis, patients who were 80 to 89 years old were more likely to undergo postoperative transfusion according to the physician's discretion (p = 0.001) compared to the aged 65 to 79 cohort (Table 3). Following adjustment on multivariate analysis to control for the differences in baseline characteristics, patients in the aged 80 to 89 cohort no longer had an increased risk of postoperative transfusion (p = 0.117) compared to patients in the aged 65 to 70 cohort (Figure 1). There were no differences in readmission, reoperation, or death between the two cohorts (Table 4).

Table 3.

Bivariate analysis of postoperative complications of total elbow arthroplasty patients.

30-day outcomes^a	65-79 years old (N = 289)	80-89 years old (N = 101)	P-value*
Superficial surgical site infection	3 (1.0)	0 (0.0)	0.304
Deep surgical site infection	2 (0.7)	0 (0.0)	0.402
Organ space infection	2 (0.7)	1 (1.0)	0.768
Wound dehiscence	5 (1.7)	0 (0.0)	0.183
Pneumonia	5 (1.7)	0 (0.0)	0.183
Pulmonary embolism	4 (1.4)	0 (0.0)	0.235
Reintubation	4 (1.4)	0 (0.0)	0.235
Urinary tract infection	0 (0.0)	1 (1.0)	0.090
Stroke	0 (0.0)	1 (1.0)	0.090
Postoperative transfusion	9 (3.1)	12 (11.9)	0.001
Deep vein thrombosis	1 (0.3)	0 (0.0)	0.554
Myocardial infarction	1 (0.3)	1 (1.0)	0.435
Extended length of stay (>8 days)	12 (4.2)	4 (4.0)	0.933
Readmission	18 (8.6)	4 (5.2)	0.341
Reoperation	15 (5.2)	2 (2.0)	0.174
Death	2 (0.7)	0 (0.0)	0.402

*Pearson's chi-squared test.

The values represent the number of patients, with the percentage indicated in parentheses.

Bolding equals significance p < 0.05.

Table 4.

Multivariate analysis of postoperative complications of total elbow arthroplasty patients.

80-89 years old (versus 65-79 years old) 30-day outcomes	Odds ratio	95% CI		P-value
Postoperative transfusion	2.226	0.819	6.049	0.117

CI: confidence interval.

Bolding equals significance p < 0.05.

Discussion

Octogenarians have been shown to have differences in risk for morbidity and mortality following various orthopaedic and non-orthopaedic surgeries compared to their younger geriatric counterparts. However, whether or not any differences in risks exist between octogenarians and younger geriatric patients undergoing TEA has not yet been explored in the literature. After controlling for the differences in baseline characteristics between the aged 65 to 79 cohort and the aged 80 to 89 cohort, this study showed for the first time that octogenarians do not have an increased risk of complications, readmission, or mortality following TEA.

Prior studies have shown satisfactory outcomes using TEA in the geriatric population.^19–22 A retrospective study of twenty-one patients showed that TEA provides reliable and satisfactory functional results when used for distal humerus fractures in patients over the age of 70.¹⁹ Similarly, authors who conducted a retrospective study concluded that TEA provides good functional outcomes comparable to open reduction and internal fixation (ORIF) for distal humerus fractures among patients with a mean age in the 70s.²² Likewise, in a multi-institutional study of patients (mean age 79 years) who underwent TEA following a distal humerus fracture, 87% of patients were pain-free or had only slight pain in their elbow post-operatively (at least 6 months follow-up).²¹ TEA has also been shown to be relatively reliable for patients with primary elbow osteoarthritis.²⁰ Among patients with a geriatric mean age of 68 years, a case series showed that TEA provided adequate pain relief and satisfaction although not a significant improvement in extension range of motion.²⁰

Our study's findings of no increased risk of complications, readmission, or mortality for octogenarians are consistent with prior orthopaedic literature. Among patients undergoing primary total ankle arthroplasty (TAA), patients over the age of 80 were not significantly more likely to develop any complication compared to those under age 80.²³ Similarly, in a study of 422 patients who underwent TKA by Cheung et al. the incidence of post-operative complications between patients over the age of 80 (12.8%) and those under age 80 (12.9%) were similar.²⁴ Moreover, Gil et al. showed that octogenarians undergoing ORIF for ankle fractures did not have a significantly higher rate of mortality or complications compared to the younger geriatric cohort aged 65 to 79 years.²⁵ Additionally, octogenarians undergoing revision total shoulder arthroplasty (RTSA) were not found to be at increased risk for thirty-day readmissions, mortality, or extended length of stay compared to younger geriatric patients.²⁶

However, there are several studies in contrary to our findings that showed an increased risk for octogenarians undergoing certain orthopaedic procedures. Murphy et al. found that patients over age 80 undergoing primary TKA had a higher risk of a longer hospital stay, medical complications, and mortality than patients under 80.²⁷ However, that study was limited in that data was from a single-institution and the comparison group was all patients under age 80 and not just the younger geriatric patients (ages 65 to 79).²⁷ Similarly, Klasan et al. conducted a retrospective review and found that patients over the age of 80 undergoing unilateral or bilateral TKA had a higher rate of mortality and general complications compared to the younger geriatric cohort (ages 61 to 78).²⁸ Additionally, in an analysis of 66,389 patients who underwent primary total hip arthroplasty (THA), age over 80 years was found to be an independent risk factor for 30-day complications and mortality.²⁹ Furthermore, in a large retrospective study, octogenarians undergoing primary THA were found to be at a greater risk of dislocation, venous thromboembolism (VTE), mortality, and readmission compared to a younger geriatric grouped aged 65 to 69 years.³⁰ Moreover, patients aged 80 or older undergoing posterolateral lumbar or lumbosacral spinal fusion surgery have been shown to be at a significantly increased risk for experiencing at least one major complication, ninety-day mortality, and 1-year mortality compared to a younger geriatric cohort aged 65 to 79 years. Likewise, in an analysis of 1495 geriatric patients (age > 65 years), age greater than 82 years was found to be an independent risk factor for in-hospital postoperative pneumonia following surgery for intertrochanteric fractures.³¹

As with all other studies, this study is not without limitations. Given that this study used a large database, it is prone to erroneous data entry or omission. Also, this database includes only patients from participating hospitals in the US. Therefore, generalization of the results of the present study to patients from non-participating hospitals and healthcare systems outside of the US may not be relevant. Another limitation of this study is that other patient comorbidities were not analyzed, such as general renal function or other cardiovascular diseases, as they are not reported in the NSQIP database. Additionally, our study did not stratify the results by indication for TEA, such as whether the patient had undergone the procedure for primary osteoarthritis or a distal humerus fracture and thus should be further explored. It is also possible that the relative potential for adverse outcomes following a TEA may not influence a physician's decision-making as the need for a TEA may outweigh the risk of any complication. Moreover, our study only looked at complications, readmissions, and mortality within a 30-day period. Data from several months or years post-operatively are warranted as the length of time may highlight different risks. Future studies on TEA should also look at functional outcomes, quality of life, and satisfaction rates between octogenarians and their younger geriatric counterparts as well to examine any possible differences. For example, Goh et al. found that octogenarians undergoing primary TKA were less satisfied at 2 years post-operatively compared to patients aged 65 to 74 years.³² Future studies should also evaluate non-operative treatments in the geriatric population and compare such procedures to TEA.

In conclusion, octogenarians are not an increased risk of complications, readmissions, or mortality following TEA compared to their younger geriatric counterparts aged 65 to 79. Age above 80 should not be used alone as an independent factor when evaluating whether a patient is an appropriate candidate for TEA.

Disclosure

Each author certifies that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Ethics

The study was deemed exempt from institutional review board approval.

ORCID iDs

Puneet Gupta

Theodore Quan

Joseph E. Manzi

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