Hip replacement surgery is on the rise, according to the Centers for Disease Control and Prevention — including among patients who are 75 and older. But is this major surgery a good idea for the oldest of the old — people in their 90s? Experts say total hip replacement is safe for 90-plus seniors in reasonably good health, and they deserve the same chance at pain relief and restored mobility as younger patients.

Encroaching Arthritis

Somebody over 90 would have the same reasons as others to consider hip replacement, says Dr. Alexander Miric, an orthopedic surgeon at Kaiser Permanente in Los Angeles. One common cause is osteoarthritis. The rate and severity of arthritis increases with age, he says, so it tends to be extremely advanced for arthritic patients in their 80s and 90s.

“The ability to walk, the ability to do tasks, to live their lives independently — that’s important to all of us, but particularly to people of that age,” Miric says. When people can no longer function because of pain and disability, he says, “joint replacement can have a profound effect.”

Hip-Fracture Fallout

A hip fracture following a fall is the other primary reason for hip replacement in elderly patients, says Dr. Sharat Kusuma, director of adult reconstruction at Grant Medical Center in Columbus, Ohio.

For somebody in their 80s or 90s, a broken hip “is an operative injury,” Kusuma says. “The hip bone is not the kind of bone that would heal on its own without some type of plates and screws, and some type of rod.”

When a fall results in hip trauma for an elderly patient, “a hip replacement is a pretty good option, because we can immediately get them up and walking the very next day after surgery, Kusuma says. Recovery is much longer if surgeons try to fix the broken hip, he adds.

Hip replacement after a bad fall presents a different scenario than elective surgery for arthritis cases, Miric says. “If someone has fallen and broken their hip, then surgery is a lifesaving procedure,” he says. “Because the mortality of broken hip without surgery is extremely, extremely high.”

Outlook for 90-Somethings

Last year, Miric led a study looking at how patients in their 90s fared with total hip replacement compared to younger patients, using a Kaiser database of more than 43,000 procedures performed nationwide over a decade. Of those, 183 patients were in their 90s — believed to be the most such cases analyzed in a single study.

For patients in the 90-plus group, hospital stays afterward were slightly longer — about a half-day more than for the youngest patients. Readmission rates were higher for the oldest group within the first three months.

While all patients in their 90s survived the surgery and postoperative periods, their death rate was higher at one year after surgery, at 5.5 percent. In contrast, the one-year mortality rate was 3.2 percent for patients in their 80s and less than 1 percent for patients under 80. (For context, Miric notes that in the general population, people age 90-plus have higher one-year death rates than the study patients.)

In the study, for complications such as infections, deep vein blood clots or lung embolisms, surgical risks were no higher for patients in their 90s.

The 90-plus group of patients did better than expected from older studies with fewer patients. Improved surgical and anesthetic techniques, better medications and possibly healthier patients all contribute, Miric says. For surgeons in the field, he adds, the study “confirms what many of us suspected — that these patients can do quite well.”

Medical Issues

“If you’re lucky enough to reach the age of 90, you are likely to have more medical issues,” Miric says. The oldest patients in Miric’s study were more prone to have heart conditions before surgery, for example — although less likely to have diabetes.

Older patients can be frail, Kusuma says, and with severe frailty comes a higher risk of complications. “Certainly, in that case we would offer nonoperative treatments, like injections,” he says. “But that decision should be made on an individual basis, not just a blanket decision based on their age.”

Brain health is a concern, he says, and Alzheimer’s-type dementia would rule out a patient. “In terms of other organ systems, if [patients’] hearts and lungs are healthy, and they have no history of heart attack, or any types of lung problems or pneumonia, that would be a good candidate,” he says.

Limited mobility — from causes beyond the problem hip — would be a concern. “For example, somebody who’s had other fractures or musculoskeletal problems that prevent them from being mobile is clearly not a good candidate,” Kusuma says. But if a failing hip is their only barrier to getting around, that’s a different story.

With Surgery

“Clearly, if somebody is 90 years old, even if they’re the healthiest 90-year-old on the planet, their recovery is going to be a bit longer,” Kusuma says. After surgery, he says, these patients should be out of bed and moving as soon as possible. Prolonged immobility heightens the risk of bedsores, pneumonia and blood clots.

“Narcotic pain medicines, even for people who are younger and healthy, can cause a lot of mental problems, confusion and dizziness,” Kusuma says. Using other types of pain medicines can help keep patients’ recovery on track.

Age can affect the choice of anesthesia. Hip replacements can be done either with traditional general anesthesia or a regional anesthetic like an epidural, Kusuma says. Regional anesthetic would usually be better for a patient who’s 90, he says, to avoid side effects like confusion.

Support for Recovery

Whether they’re 90 or 45, people need help at home after hip replacement — including assistance with cooking, bathing and laundry, plus shopping for groceries and picking up prescriptions and supplies. And patients need an exercise plan to gradually increase their mobility.

Well before surgery, patients need to have supports in place for recovery, whether it’s family members or home health aides. For some people, an inpatient rehabilitation facility might be the best option to meet all their needs — from wound care to personal safety to physical therapy.

Quality of Life

Is surgery to put in an artificial joint that’s likely to outlive the patient a good use of health-care resources? “That’s a question that faces all of us much more than it did 30 years ago — and we’re going to have to face it even more in the coming years” as the nonagenarian population grows, Miric says.

He points to a 2008 study from Scotland that looked at surgery for total knee replacement among 90-year-olds. The study found the procedure was “safe, beneficial and cost-effective” as it compared costs of the surgery, which allowed patients to keep living independently, to what their nursing-home costs would have been.

Kusuma questions whether it’s possible to put a dollar value on quality of life. “If it’s your grandfather who is 90 years old and is suffering around the house and wants to be out with his family and friends — and he’s in good health and can tolerate a hip replacement — do you think that’s a wise use of health-care resources?” he asks. “That’s where the rubber meets the road in terms of decision-making.”

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Getting a Hip Replacement — in Your 90s originally appeared on usnews.com