Comment on "Total knee arthroplasty in carefully selected patients aged 80 years or older".
Raju Vaishya, Indraprastha Apollo Hospitals
10 October 2014
Sir,
We read the recently published article titled “Total knee arthroplasty in carefully selected patients aged 80 years or older” (1), with lot of interest. We agree with the authors that it is possible to do total knee arthroplasty in selected very elderly patients (octo and nonagenarians). We also have a large experience of doing TKA in this population of patients and have even done bilateral simultaneous TKA (SBTKA) in these patients (2, 3), including one case of 93 years old (4). We believe that simply chronological age of the patient should not be the reason to condone these elderly patients from the benefit of having good quality of life after TKA.
After reading the present publication, we had some concerns about the present study –
The authors have not clearly mentioned in their paper as to whether have had any case of SBTKA and if not what were the reasons for not doing such a procedure in their patients. Simultaneous bilateral total knee arthroplasty has been shown to be a safe and cost effective option for octogenarians suffering from osteoarthritis and can improve the quality of life and decrease the consumption of analgesics and possibly reduce cardiac risk (5)
This study also suffers with a bias in selecting their patients, as only very healthy individuals were recruited after clearance from cardiologists and neurologists. This could lead to “healthy cohort effect” which means that the only the healthy individuals were selected for the cohort study who would eventually have good future outcomes (6).
The authors have reported higher incidence of blood transfusion (29.3% versus 10.7%, p = 0.003) in octogenarian population compared to younger ones. The reasons given for this finding are conflicting as they have mentioned the first reason for doing so was that the octogenarian group had low mean preoperative levels of Hb and Hct, although they did not reach statistical significance but then showed that there was no significant difference in the incidence of anemia (p value: 0.459).
Despite a higher incidence of postoperative UGI bleeding in octogenarian group than in
the controls (4% versus 0%), they preferred to give a highly GI irritant drug like Indomethacin for at least 4 weeks. This needs rethinking and explanation.
It is also not discussed by the authors for their preference of General anaesthesia over regional anaesthesia (73 v/s 2) in their patient population.
References
1. Feng-Chih Kuo, Chi-Hsiang Hsu, Wun-Schen Chen, Jun-Wen Wang. Total knee arthroplasty in carefully selected patients aged 80 years or older. Journal of Orthopaedic Surgery and Research. 2014, 9:61 doi:10.1186/s13018-014-0061-z.
2. Cahill CW, Schwarzkopf R, Sinha S, Scott RD. Simultaneous bilateral knee arthroplasty in octogenarians: can it be safe and effective? J Arthroplasty. 2014 May;29(5):998-1000. doi: 10.1016/j.arth.2013.10.026. Epub 2013 Nov 4.
3. Vaishya R, Vijay V. How old is an old for simultaneous bilateral total knee arthroplasty. JAGS (in press).
4. Bheeshma Ravi, Ruth Croxford, Peter C Austin, and et al. The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysis.BMJ. 2013. 347:f6187.
5. Vijay V, Vaishya R. Letter to the Editor on "Simultaneous Bilateral Knee Arthroplasty in Octogenarians: Can It Be Safe and Effective?" J Arthroplasty. 2014 May 4. pii: S0883-5403(14)00296-4. doi: 10.1016/j.arth.2014.04.038. [Epub ahead of print]
Journal of Orthopaedic Surgery and Research
Comment on "Total knee arthroplasty in carefully selected patients aged 80 years or older".
10 October 2014
Sir,
We read the recently published article titled “Total knee arthroplasty in carefully selected patients aged 80 years or older” (1), with lot of interest. We agree with the authors that it is possible to do total knee arthroplasty in selected very elderly patients (octo and nonagenarians). We also have a large experience of doing TKA in this population of patients and have even done bilateral simultaneous TKA (SBTKA) in these patients (2, 3), including one case of 93 years old (4). We believe that simply chronological age of the patient should not be the reason to condone these elderly patients from the benefit of having good quality of life after TKA.
After reading the present publication, we had some concerns about the present study –
Despite a higher incidence of postoperative UGI bleeding in octogenarian group than in
the controls (4% versus 0%), they preferred to give a highly GI irritant drug like Indomethacin for at least 4 weeks. This needs rethinking and explanation.
It is also not discussed by the authors for their preference of General anaesthesia over regional anaesthesia (73 v/s 2) in their patient population.
References
1. Feng-Chih Kuo, Chi-Hsiang Hsu, Wun-Schen Chen, Jun-Wen Wang. Total knee arthroplasty in carefully selected patients aged 80 years or older. Journal of Orthopaedic Surgery and Research. 2014, 9:61 doi:10.1186/s13018-014-0061-z.
2. Cahill CW, Schwarzkopf R, Sinha S, Scott RD. Simultaneous bilateral knee arthroplasty in octogenarians: can it be safe and effective? J Arthroplasty. 2014 May;29(5):998-1000. doi: 10.1016/j.arth.2013.10.026. Epub 2013 Nov 4.
3. Vaishya R, Vijay V. How old is an old for simultaneous bilateral total knee arthroplasty. JAGS (in press).
4. Bheeshma Ravi, Ruth Croxford, Peter C Austin, and et al. The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysis.BMJ. 2013. 347:f6187.
5. Vijay V, Vaishya R. Letter to the Editor on "Simultaneous Bilateral Knee Arthroplasty in Octogenarians: Can It Be Safe and Effective?" J Arthroplasty. 2014 May 4. pii: S0883-5403(14)00296-4. doi: 10.1016/j.arth.2014.04.038. [Epub ahead of print]
Competing interests
No competing interests to be declared.