Early death following primary total hip arthroplasty

30-day to 10-year mortality rates following total hip arthroplasty: a meta-analysis of the last decade (2011-2021)

BACKGROUND

Mortality after total hip arthroplasty (THA) is a rare but devastating complication. This meta-analysis aimed to: (1) determine the mortality rates at 30 days, 90 days, 1 year, 5 years and 10 years after THA; (2) identify risk factors and causes of mortality after THA.

METHODS

Pubmed, MEDLINE, Cochrane, EBSCO Host, and Google Scholar databases were queried for studies reporting mortality rates after primary elective, unilateral THA. Inverse-proportion models were constructed to quantify the incidence of all-cause mortality at 30 days, 90 days, 1 year, 5 years and 10 years after THA. Random-effects multiple regression was performed to investigate the potential effect modifiers of age (at time of THA), body mass index, and gender.

RESULTS

A total of 53 studies (3,297,363 patients) were included. The overall mortality rate was 3.9%. The 30-day mortality was 0.49% (95% CI; 0.23-0.84). Mortality at 90 days was 0.47% (95% CI, 0.38-0.57). Mortality increased exponentially between 90 days and 5 years, with a 1-year mortality rate of 1.90% (95% CI, 1.22-2.73) and a 5-year mortality rate of 9.85% (95% CI, 5.53-15.22). At 10-year follow-up, the mortality rate was 16.43% (95% CI, 1.17-22.48). Increasing comorbidity indices, socioeconomic disadvantage, age, anaemia, and smoking were found to be risk factors for mortality. The most commonly reported causes of death were ischaemic heart disease, malignancy, and pulmonary disease.

CONCLUSIONS

All-cause mortality remains low after contemporary THA. However, 1 out of 10 patients and 1 out of 6 patients were deceased after 5 years and 10 years of THA, respectively. As expected, age, but not BMI or gender, was significantly associated with mortality.

Preoperative risk factors for postoperative pneumonia following primary Total Hip and Knee Arthroplasty

BACKGROUND

The purpose of this study is to evaluate risk factors for pneumonia following THA and TKA.

METHODS

Patients were identified from the American College of Surgeons National Quality Improvement Database (NSQIP) who experienced postoperative pneumonia after undergoing primary THA and TKA.

RESULTS

Many characteristics including old age, anemia, diabetes, cardiac comorbidities, dialysis, and smoking were independent risk factors for postoperative pneumonia after THA or TKA.

CONCLUSION

This analysis offers new evidence on risk factors associated with the development of pneumonia after THA and TKA. These risk factors can help guide clinicians in preventing postoperative pneumonia after THA and TKA.

Should concurrent infections be treated before performing hip arthroplasty for hip fracture?

Aims

A systematic literature review focusing on how long before surgery concurrent viral or bacterial infections (respiratory and urinary infections) should be treated in hip fracture patients, and if there is evidence for delaying this surgery.

Methods

A total of 11 databases were examined using the COre, Standard, Ideal (COSI) protocol. Bibliographic searches (no chronological or linguistic restriction) were conducted using, among other methods, the Patient, Intervention, Comparison, Outcome (PICO) template. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for flow diagram and checklist. Final reading of the complete texts was conducted in English, French, and Spanish. Classification of papers was completed within five levels of evidence (LE).

Results

There were a total of 621 hits (526 COre; 95 Standard, Ideal) for screening identification, and 107 records were screened. Overall 67 full-text articles were assessed for eligibility, and 21 articles were included for the study question. A total of 46 full-text articles were excluded with reasons. No studies could be included in quantitative synthesis (meta-analyses), and there were many confounding variables including surgeons’ experience, prosthesis models used, and surgical technique.

Conclusion

Patients with hip fracture and with a viral infection in the upper respiratory tract or without major clinical symptoms should be operated on as soon as possible (LE: I-III). There is no evidence that patients with coronavirus disease 2019 (COVID-19) should be treated differently. In relation to pneumonia, its prevention is a major issue. Antibiotics should be administered if surgery is delayed by > 72 hours or if bacterial infection is present in the lower respiratory tract (LE: III-V). In patients with hip fracture and urinary tract infection (UTI), delaying surgery may provoke further complications (LE: I). However, diabetic or immunocompromised patients may benefit from immediate antibiotic treatment.

Cite this article: Bone Joint Res 2020;9(12):884–893.

Predictors of mortality following shoulder arthroplasty

Introduction

This study aims to determine 30-day, 90-day and 1 year mortality following shoulder arthroplasty and identify predictors of mortality.

Materials and methods

All shoulder arthroplasty cases performed at the host institution, between 2012 and 2018 were included. A review of patient records was completed to identify demographic data, Charlson comorbidity index, date of death and factors associated with mortality.Mortality analysis was undertaken using 1-Kaplan Meier estimates with 95% confidence intervals. Comparative analysis was performed for mortality following shoulder arthroplasty for elective vs. trauma and for primary vs. revision surgery. A multiple regression analysis was conducted to determine which factors were associated with increased mortality risk.

Results

640 shoulder arthroplasty cases were performed in 566 patients. There were 44 deaths, 1 occurred within 90 days and 13 within 1 year. Trauma procedures had a hazard ratio of 5.3 (95% CI 1.9 to 15.0) for mortality compared to elective procedures (5 year survival trauma 78.6% (95% CI 60.7 to 89.0); elective 91.8% (95% CI 88.1 to 94.4). 1-year mortality was predicted by presence of malignancy, liver failure, cardiac failure, peptic ulcer, trauma surgery, revision surgery, intra-operative complication, transfusion and increased length of stay.

Discussion

30-day, 90-day and 1-year mortality following shoulder arthroplasty were 0%, 0.16% and 2%; trauma procedures had a hazard ratio of 5.3 for 1-year mortality when compared to elective surgery. Malignancy, cardiac failure, liver failure, peptic ulcer and trauma surgery are associated with an increased risk of 1-year mortality.

Early death following revision total knee arthroplasty

All patients from our institution who underwent revision total knee arthroplasty (TKA) or were added to the waiting list for revision TKA between 2003 and 2013 were analysed to describe the timing and degree of excess early surgical mortality. We measured the excess surgical mortality at 90-days for the revision TKA group compared to the waiting list group as 0.37% (95% CI 0.10%-0.65%, p = 0.075). A larger sample size will be required to give a more accurate measurement and thus we encourage other authors with access to larger cohorts to use our methods to quantify excess mortality after revision TKA.

A Simple Protocol to Stratify Pulmonary Risk Reduces Complications After Total Joint Arthroplasty

BACKGROUND

Pulmonary complications after total joint arthroplasty are a burden to patients and the healthcare system. The aim of this study is to demonstrate the effectiveness of a pulmonary screening questionnaire and intervention protocol developed at our institution to prevent pulmonary complications.

METHODS

Between 2010 and 2015, 7658 consecutive total joint arthroplasty patients at our institution were reviewed. Based on our pre-operative pulmonary risk assessment tool, 1625 patients were flagged as high pulmonary risk. Patients were determined to be high risk if they were a current or former heavy smoker with an abnormal spirometry, had a positive obstructive sleep apnea screening, required continuous positive airway pressure/bi-level positive airway pressure use, had a history of significant pulmonary disease, had an oxygen saturation <90%, or had body mass index >40. A standardized monitoring protocol and interventions including smoking cessation, treatment and optimization of primary pulmonary conditions, peri-operative inhaler use, spinal anesthesia, aspiration precautions, elevated head of bed >20° resting and >45° while eating, maintaining oxygen saturation ≥92%, early use of incentive spirometer, avoidance of narcotics and early respiratory therapy consult were initiated for all high risk patients.

RESULTS

Only 7 of 7658 (0.091%) patients suffered pulmonary complications after initiating our intervention protocol. These included 3 aspiration pneumonias, 1 asthma exacerbation, 1 chronic obstructive pulmonary disease exacerbation, 1 continuous positive airway pressure intolerance in a patient with obstructive sleep apnea, and 1 requirement of bi-level positive airway pressure. The pulmonary risk questionnaire accurately identified all patients who had pulmonary complications. The overall pulmonary complication rate at our institution decreased from 5.7% to 0.09% after implementing our screening questionnaire and intervention protocol (P < .0001).

CONCLUSION

Our results demonstrate a more than 63-fold reduction in pulmonary complications at our institution. Our screening questionnaire and intervention protocol is an effective way of identifying and preventing pulmonary complications.

Early death following revision total hip arthroplasty

INTRODUCTION

The frequency of primary total hip arthroplasty procedures is increasing, with a subsequent rise in revision procedures. This study aims to describe timing and surgical mortality associated with revision total hip arthroplasty (THA) compared to those on the waiting list.

METHODS

All patients from a single institution who underwent revision total hip arthroplasty or were added to the waiting list for the same procedure between 2003 and 2013 were recorded. Mortality rates were calculated at 30 and 90 days following surgery or addition to the waiting list.

RESULTS

561 patients were available for the survivorship analysis in the surgical group. Following exclusion, 901 and 484 patients were available for the 30 and the 90-day analysis in the revision THA waiting list group. 30- and 90-day mortality rates were significantly greater for the revision THA group compared to the waiting list group (excess surgical mortality at 30 days = 0.357%, p = 0.037; odds ratio of 5.22, excess surgical mortality at 90 days = 0.863%, p = 0.045).

CONCLUSIONS

Revision total hip arthroplasty is associated with a significant excess surgical mortality rate until 90 days post-operation when compared to the waiting list population. We would encourage other authors with access to larger samples to use our method to quantify excess mortality after both primary and revision arthroplasty procedures.

The Main Cause of Death Following Primary Total Hip and Knee Replacement for Osteoarthritis: A Cohort Study of 26,766 Deaths Following 332,734 Hip Replacements and 29,802 Deaths Following 384,291 Knee Replacements

BACKGROUND

Patients undergoing primary total joint replacement are selected for surgery and thus (other than having a transiently increased mortality rate postoperatively) have a lower mortality rate than age and sex-matched individuals do. Understanding the causes of death following joint replacement would allow targeted strategies to reduce the risk of death and optimize outcome. We aimed to determine the rates and causes of mortality for patients undergoing primary total hip or knee replacement compared with individuals in the general population who were matched for age and sex.

METHODS

We compared causes and rates of mortality between age and sex-matched individuals in the general population (National Joint Registry for England, Wales and Northern Ireland; Hospital Episode Statistics; and Office for National Statistics) and a linked cohort of 332,734 patients managed with total hip replacement (26,766 of whom died before the censoring date) and 384,291 patients managed with primary total knee replacement (29,802 of whom died before the censoring date) from 2003 through 2012.

RESULTS

The main causes of death were malignant neoplasms (33.8% [9,037] of 26,766 deaths in patients with total hip replacement and 33.3% [9,917] of 29,802 deaths in patients with total knee replacement), circulatory system disorders (32.8% [8,784] of the deaths in patients with total hip replacement and 33.3% [9,932] of the deaths in patients with total knee replacement), respiratory system disorders (10.9% [2,928] of the deaths in patients with total hip replacement and 9.8% [2,932] of the deaths in patients with total knee replacement), and digestive system diseases (5.5% [1,465] of the deaths in patients with total hip replacement and 5.3% [1,572] of the deaths in patients with total knee replacement). There was a relative reduction in mortality (39%) compared with the individuals in the general population that equalized to the rate in the general population by 7 years for hips (overall standardized mortality ratio [SMR], 0.61; 95% confidence interval [CI], 0.60 to 0.62); for knees, the relative reduction (43%) partially attenuated by 7 years but still had not equalized to the rate in the general population (overall SMR, 0.57; 95% CI, 0.56 to 0.57). Ischemic heart disease was the most common cause of death within 90 days (29% [431] of the deaths in patients with primary hip replacement and 31% [436] of the deaths in patients with primary knee replacement). There was an elevated risk of death from circulatory, respiratory, and (most markedly) digestive system-related causes within 90 days postoperatively compared with 91 days to 1 year postoperatively.

CONCLUSIONS

Ischemic heart disease is the leading cause of death in the 90 days following total joint replacement, and there is an increase in postoperative deaths associated with digestive system-related disease following joint replacement. Interventions targeted at reducing these diseases may have the largest effect on mortality in total joint replacement patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Time course and reasons for 90-day mortality in fast-track hip and knee arthroplasty

BACKGROUND

Post-operative mortality is an important adverse outcome, including in total hip (THA) and knee arthroplasty (TKA). However, whether mortality is due to anaesthetic/surgical complications, surgically induced organ dysfunction or unrelated to surgery is rarely considered.

METHODS

Prospective observational study in 13,775 consecutive THA/TKAs with similar fast-track protocols and a median length of stay of 2 days. Complete 90-days follow-up through national registries, followed by review of medical records and death certificates. Relation between mortality and surgically induced organ dysfunction were classified as certain, probable, possible or unlikely.

RESULTS

Of a total of 44 deaths (0.3%), 28 (0.2%) were found to have certain or probably relation with surgery and were considered as surgery-related. Surgery-related deaths were more common after THA than TKA (0.3% vs. 0.1% P = 0.044), occurred after median 14 days and 19 of 28 were between day 0-30. Of the remaining 16 deaths (0.1%), nine were found to be possible and seven to be unlikely related to surgery, and occurred a median of 42 and 61 days after surgery. The most common initial organ dysfunction for surgery-related deaths was pulmonary (6/28) and gastrointestinal (6/28), while the most common reported cause of death were pulmonary (9/28) and cardiac events (6/28). In five of the seven unlikely related deaths mortality was attributed to underlying cancer.

CONCLUSION

Ninety-days mortality was 0.3% in THA and TKA, but only 28 of 44 deaths (64%) were found to be surgery-related. Reporting total mortality rate or cause of death without considerations on surgery induced organ dysfunction, may be insufficient for future aims to reduce post-operative mortality.

Risk of early mortality after cemented compared with cementless total hip arthroplasty

Aims

It has been suggested that cemented fixation of total hip arthroplasty (THA) is associated with an increased peri-operative mortality compared with cementless THA. Our aim was to investigate this through a nationwide matched cohort study adjusting for age, comorbidity, and socioeconomic background.

Patients and Methods

A total of 178 784 patients with osteoarthritis who underwent either cemented or cementless THA from the Swedish Hip Arthroplasty Register were matched with 862 294 controls from the general population. Information about the causes of death, comorbidities, and socioeconomic background was obtained. Mortality within the first 90 days after the operation was the primary outcome measure.

Results

Patients who underwent cemented THA had an increased risk of death during the first 14 days compared with the controls (hazard ratio (HR) 1.3, confidence interval (CI) 1.11 to 1.44), corresponding to an absolute increase in risk of five deaths per 10 000 observations. No such early increase of risk was seen in those who underwent cementless THA. Between days 15 and 29 the risk of mortality was decreased for those with cemented THA (HR 0.7, CI 0.62 to 0.87). Between days 30 and 90 all patients undergoing THA, irrespective of the mode of fixation, had a lower risk of death than controls. Patients selected for cementless fixation were younger, healthier and had a higher level of education and income than those selected for cemented THA. A supplementary analysis of 16 556 hybrid THAs indicated that cementation of the femoral component was associated with a slight increase in mortality up to 15 days, whereas no such increase in mortality was seen in those with a cemented acetabular component combined with a cementless femoral component.

Conclusion

This nationwide matched cohort study indicates that patients receiving cemented THA have a minimally increased relative risk of early mortality that is reversed from day 15 and thereafter. The absolute increase in risk is very small. Our findings lend support to the idea that cementation of the femoral component is more dangerous than cementation of the acetabular component. Cite this article: Bone Joint J 2017;99-B:37–43.

Inpatient mortality after elective primary total hip and knee joint arthroplasty in Botswana

PURPOSE

Total hip and knee joint arthroplasty (TJA) rank among the most successful orthopaedic operations. Several developing countries in Africa have started to perform these procedures that are routine in developed countries. The aims of this study were to measure the incidence and assess the determinants of in-hospital mortality after elective primary TJA in our unit and compare it with published data.

METHODS

This was a retrospective study of the first consecutive cohort of patients who underwent elective primary TJA in Princess Marina Hospital, Botswana between March 2009 and October 2015 (6.5 years).

RESULTS

346 elective joint replacements were performed comprising 153 total hip arthroplasties (THA) and 193 total knee arthroplasties (TKA); 36 % of the THA were in female patients and 82 % of TKA were in females. The mean age was 64.5 years (range 26-86). Three patients died giving an inpatient mortality rate of 0.86 %. These three mortalities represent 1.55 % (three out of 193) of all the TKA. There were no deaths after THA. The cause of mortality in two patients was an adverse cardiac event while the third mortality was due to pulmonary embolism.

CONCLUSION

The inpatient mortality rate of 0.86 % following TJA is higher than the reported rates in the developed countries but comparable with data from other developing countries. The inpatient mortality rate following TKA was higher than that following THA and cardiovascular events proved to be the main cause of death. We recommend formal cardiology assessment and close peri-operative monitoring of all patients with a history of cardiovascular disease undergoing TJA.

Adverse cardiac events in 56,000 orthopaedic trauma patients: Does anatomic area make a difference?

PURPOSE

Postoperative cardiac events in orthopaedic trauma patients constitute severe morbidity and mortality. It is therefore increasingly important to determine patient risk factors that are predictive of postoperative myocardial infarctions and cardiac arrests. This study sought to assess if there is an association between anatomic area and cardiac complications in the orthopaedic trauma patient.

PATIENTS AND METHODS

From 2006-2013, a total of 361,402 orthopaedic patients were identified in the NSQIP database using Current Procedural Terminology (CPT) codes. Of these, 56,336 (15.6%) patients were identified as orthopaedic trauma patients broken down by anatomic region: 11,905 (21.1%) upper extremity patients (UE), 29,009 (51.5%) hip/pelvis patients (HP), and 15,422 (27.4%) lower extremity patients (LE) using CPT codes. Patients were defined as having adverse cardiac events if they developed myocardial infarctions or cardiac arrests within 30days after surgery. Chi-squared analysis was used to determine if there was an association between anatomic area and rates of cardiac events. Multivariate logistical analysis was used with over 40 patient characteristics including age, gender, history of cardiac disease, and anatomic region as independent predictors to determine whether anatomic area significantly predicted the development of cardiac complications.

RESULTS

There were significant differences in baseline demographics among the three groups: HP patients had the greatest average age (77.6 years) compared to 54.8 years for UE patients and 54.1 years in LE patients (p<0.001). HP patients also had the highest average ASA score (3.0) (p<0.001). There was a significant difference in adverse cardiac events based on anatomic area: 0.27% (32/11,905) UE patients developed cardiac complications compared to 2.15% (623/29,009) HP patients and 0.61% (94/15,422) LE patients. After multivariate analysis, HP patients were significantly more likely to develop cardiac complications compared to both UE patients (OR: 6.377, p=0.014) and LE patients (OR: 2.766, p=0.009).

CONCLUSION

There is a significant difference in adverse cardiac events following orthopaedic trauma based on anatomic region. Hip/Pelvis surgery appeared to be a significant risk factor in developing an adverse cardiac event. Further studies should investigate why hip/pelvic patients are at a higher risk of adverse cardiac events.

Early Pulmonary Complications following Total Knee Arthroplasty under General Anesthesia: A Prospective Cohort Study Using CT Scan

Purpose. Postoperative pulmonary complications (PPCs) are common after major surgeries. However, the number of studies regarding PPCs following total knee arthroplasty (TKA) is limited. The aim of this study was to determine the incidence of early PPCs following TKA by computed tomography (CT) scan and to identify associated risk factors. Methods. Patients, who were diagnosed with osteoarthritis or rheumatoid arthritis and underwent primary TKA at our institution, were included in this prospective cohort study. Patients received a standard procedure of TKA under general anesthesia. Chest CT scan was performed during 5–7 days postoperatively. Univariate analysis and multivariate logistic regression analysis were employed to identify the risk factors. Results. The total incidence of early PPCs following TKA was 45.9%. Rates of pneumonia, pleural effusion, and atelectasis were 14.4%, 38.7%, and 12.6%, respectively. Lower body mass index and perioperative blood transfusion were independent risk factors for PPCs as a whole and associated with atelectasis. Postoperative acute episode of hypoxemia increased the risk of pneumonia. Blood transfusion alone was related to pleural effusion. Conclusions. The incidence of early PPCs following TKA was high. For patients with relevant risk factors, positive measures should be adopted to prevent PPCs.

Do orthopaedic trauma patients develop higher rates of cardiac complications? An analysis of 56,000 patients

PURPOSE

Less than 5 % of orthopaedic patients develop postoperative cardiac complications; however, there are little data suggesting which orthopaedic patients are at greatest risk. In an era where emerging reimbursement models place an emphasis on quality, reducing complications through perioperative planning will be of paramount importance for orthopaedic surgeons. The purpose of this study was to determine whether orthopaedic trauma patients are at greater risk for postoperative cardiac complications and to reveal which factors are most predictive of these complications.

METHODS

All orthopaedic patients were identified in the 2006-2013 ACS-NSQIP database. Cardiac complications were defined as cardiac arrests or myocardial infarctions within 30 days following surgery. Chi squared analysis determined differences in cardiac complication rates between trauma and non-trauma patients. Bivariate analysis incorporating over 40 patient/surgical characteristics determined significant associations between patient characteristics and cardiac complications. These factors were incorporated into a multivariate regression model to identify predictive risk factors for cardiac complications.

RESULTS

The presence of a traumatic injury resulted in greater odds of developing cardiac complications (OR: 1.645, p < 0.001). The cardiac complication rate in the trauma group was 1.3 % compared to 0.3 % in the non-trauma group (p < 0.001). For trauma patients, ventilator use (OR: 27.354, p = 0.004), recent transfusion (OR: 19.780, p = 0.001), and history of coma (OR: 17.922, p = 0.020) were most predictive of cardiac complications.

CONCLUSION

Orthopaedic trauma patients are more likely to develop cardiac complications than non-trauma patients. To reduce cardiac complications, orthopaedic traumatologists should be aware of patient risk factors including ventilator use, blood transfusion, and history of coma.