Longer hospital stay,more complications,and increased mortality but substantially improved function after knee replacement in older patients: A study of 3,144 primary unilateral total knee replacements

Background and purpose

Total knee replacement (TKR) is being increasingly performed in elderly patients, yet there is little information on specific requirements and complication rates encountered by this group. We assessed whether elderly patients undergoing TKR had different length of stay, requirements, complication rates, and functional outcomes compared to younger counterparts.

Patients and methods

We analyzed prospectively gathered data on 3,144 consecutive primary TKRs (in 2,092 patients aged less than 75 years, 694 patients aged between 75 and 80 years, and 358 patients aged over 80 years at the time of surgery).

Results

Incidence of blood transfusion, urinary catheterization, postoperative confusion, cardiac arrhythmia, and 1-year mortality increased with age, even after adjusting for confounding factors, whereas the incidences of chest infection and mortality at 1 month were highest in those aged 75–80. Rates of thromboembolism, prosthetic infection, and revision were similar in the 3 age groups. All groups showed similar substantial improvements in American Knee Society (AKS) knee scores, which were maintained at 5 years. Older patients had smaller improvements in AKS function score, which deteriorated between 3 and 5 years postoperatively, in contrast to the younger group.

Interpretation

Elderly people stand to gain considerably from TKR, particularly in terms of pain relief, and they should not be denied surgery based solely on age. However, they should be warned that they can expect a longer length of stay, a higher requirement for blood transfusion and/or urinary catheterization, and more medical complications postoperatively. Mortality was also higher in the older age groups. The risks have been quantified to assist in perioperative counselling, informed consent, and healthcare planning.Healthcare systems and medical professionals will need to cater for increasing numbers of total knee replacements (TKRs) in elderly people in the coming years (Carr et al. 2012), but little is known about inpatient requirements and the postoperative complications suffered by this particular patient group. Some studies have shown good joint-specific pain relief and functional benefits from TKR in the elderly (Anderson et al. 1996, Birdsall et al. 1999), although it has been suggested that elderly patients may attain lower global function than their younger counterparts (Clement et al. 2011, Kennedy et al. 2013). However, studies attempting to describe complications in the elderly undergoing TKR have been small (Zicat et al. 1993, Hosick et al. 1994, Joshi et al. 2003), have lacked comparator groups (Hosick et al. 1994, Joshi et al. 2003), or have failed to quantify the time scales within which complications have occurred (Clement et al. 2011, Kennedy et al. 2013). Other studies and registries have been based on discharge summary databases without specific patient follow-up (Kreder et al. 2005, Mahomed et al. 2005, Scottish Arthroplasty Project, 2012). They therefore relied on third-party coding of discharge summaries and reported only on mortality during the index admission (Kreder et al. 2005) or selected complications requiring hospital re-admission within 30 or 90 days (Kreder et al. 2005, Mahomed et al. 2005, Scottish Arthroplasty Project, 2012).The aim of this study was to determine whether elderly patients undergoing TKR had different postoperative length of stay, inpatient requirements (i.e. blood transfusion and urinary catheterization), complication rates, and mortality rates to those of their younger counterparts. Functional outcomes were assessed as a secondary outcome measure, to determine whether elderly patients gained benefit comparable to that of their younger counterparts, independently of recorded admission requirements and complications.     

Tuberculosis recurrences: reinfection plays a role in a population whose clinical/epidemiological characteristics do not favor reinfection

BACKGROUND: Tuberculosis (TB) recurrences can be due to either reactivation by the same strain (standard assumption) or reinfection by a new strain. Reinfection has mainly been studied in selected populations with a high risk of reexposure to TB. Our aim was to analyze the role of reinfection in TB recurrences in unselected populations, without the clinical/epidemiological circumstances that favor the involvement of a new different strain of Mycobacterium tuberculosis in the recurrence. METHODS: A molecular typing analysis was performed with 92 sequential isolates of M tuberculosis from 43 patients with recurrent TB, during a 12-year period. The subjects were both positive and negative for the human immunodeficiency virus, most did not adhere to anti-TB therapy, and they lived in an area with a moderate incidence of TB. Recurrence was considered as being caused by reinfection when the molecular fingerprints for the strains involved in the sequential episodes of TB were different. RESULTS: In 14 (33%) of the 43 patients, different M tuberculosis strains were involved in the first and in subsequent episodes of TB. Reinfection was found for patients who were both positive and negative for the human immunodeficiency virus, and most patients did not adhere to anti-TB therapy. Differences between the reinfection and reactivation groups were not significant (P =.77) according to the time interval between episodes. CONCLUSIONS: Reinfection plays an important role in recurrent TB in a population without the clinical/epidemiological circumstances that are usually assumed to favor it. Reinfection should, thus, be considered as a cause of TB recurrences in a wider context than before.     

Esthetic considerations for the treatment of the edentulous maxilla based on current informatic alternatives: a case report

This report presents a protocol used to transfer the virtual treatment plan data to the surgical and prosthetic reality and its clinical application, bone site augmentation with computer-custom milled bovine bone graft blocks to their ideal architecture form, implant insertion based on image-guided stent fabrication, and the restorative manufacturing process through computed tomography-based software programs and navigation systems and the computer-aided design and manufacturing techniques for the treatment of the edentulous maxilla.     

Enteropathy-associated intestinal t-cell lymphoma without celiac disease

Type II enteropathy-associated T-cell lymphoma (EATL) is an uncommon intestinal lymphoma. We report the case of a 73-year-old man with diarrhea and weight loss. Duodenal biopsy showed atrophy and infiltration of irregular lymphocytes. Immunohistochemistry was positive for CD3, CD8, and CD56 with monoclonal TCR rearrangement. The HLA-DQ genotype was DQ5/DQ9. The Epstein-Barr virus RNA test was negative. Before specific chemotherapy could be administered, the patient was admitted to hospital for a respiratory infection and died from a cause unrelated to his lymphoma. The differential diagnosis of CD56-positive lymphoproliferative processes include type II EATL, primary T-cell/natural killer-cell intestinal lymphoma and hepatosplenic T-cell lymphoma. The patient had CD8 y CD56+ markers that allowed type I EATL to be excluded. The HLA-DQ genotype did not correspond to celiac disease and the biopsy showed proliferation of lymphocytes with atypia. The primary intestinal T-cell/natural killer-cell lymphoma was characterized mainly by the absence of CD8 and monoclonal reassortment of the TCR present in this case.