How old is too old?

While it seems lately a lot of focus is on younger patients and the increasing demands of active people, we sometimes forget that the vast majority of those who need hip and knee replacements are the elderly.

The fastest growing demographic segments for hip and knee replacements are the young, but still the majority of surgeries are on those 70 years old and up.  Why is this?  Mostly because as surgeons, the classic 75 year old senior citizen, is still young enough to be relatively healthy, and old enough that they will only need 1 surgery (assuming a prosthesis lasts around 20+ years) in their lifetime.

And while I regularly hear from patients that someone (their family doctor, therapist, friend, or another orthopaedic surgeon) told them they are too YOUNG to have surgery, I also hear the opposite:

“Do I still qualify for hip/knee replacement at my age?”

“I’m too old to have an anaesthetic.”

“My doctor wouldn’t refer me because they thought I was too old”

“Will the government pay for this at my age?”

The reality is, the older we get, the more surgical risk their is.  And while it increases slowly every year, their is no theoretical cut-off, based on age.  OHIP (Ontario Health Insurance) doesn’t cease at 85, or any other number.  And while geneologcial age is a factor, the most important consideration is PHYSIOLOGICAL AGE.

When it comes to surgery, age truly is a just a number.  More of a guide really.  Physiologically  – or what condition your body is in, is more important.  This is why traditionally your surgeon asks about your general health, previous surgeries, hospitalizations and medications.  These days, peoples’ lifestyles are just as important:

“Do you smoke or drink excessively?”

“How often do you exercise?  What is your fitness like?”

These are important questions, because all surgery will place stress on your body.  Your surgical candidacy is based on if you body can handle the stress to you heart, lungs, muscles and your ability to recover.  And while traditionally, theses stresses are better handled by younger people, as a surgeon, I’ve seen 40-years olds that looked at least 25  years older, and 65-year olds healthier than those half their age.

When it does come to the elderly, some of the things that specifically worry me from an technical orthopaedic perspective based on age include:
BONE DENSITY – The older we get, the less dense our bones become.  This can lead to an increase risk of intra-operative fractures (a potential complication of hip or knee replacement). Calcium, Vitamin D, resistance training and certain medications can help maintain bones density as we age.

CONTRACTURES – With time, arthritic joints become stiff.  After a certain point, deformities and contractures become difficult to correct fully.  The manipulation of exceedingly stiff limbs during surgery, can also lead to potential intra-operative fractures.

HEALING – With age, bones, muscles, tendons and surgical wounds take on average longer to recover and heal.  Patience and extra care are needed in the immediate post-operative phase.

In summary, your surgical candidacy is a factor of many things, not just your birth certificate.  A lot has changed over the years, and your surgical experience is now a function of a carefully orchestrated process and a group of health care workers making it safer than ever to undergo invasive procedures.  Anaesthesia is very targeted, there is significantly less blood loss in surgery, and overall  procedures are faster and less invasive.  Pre and post-operative care is also better, reducing complications.

If you are independent, exercise regularly, have no major cardiac or respiratory risk factors and take minimal prescription medications – you are NOT too old for surgery. Regardless of age.  I’ve operated electively on 75, 85 and even 95 year olds.