Thirty-Day mortality after elective hip and knee arthroplasty

Early Mortality Rate and Associated Risk Factor in Patients Undergoing Primary Total Hip Replacement at a Tertiary Hospital in Tanzania

Background: Hip joint replacement surgery or total hip arthroplasty (THA) is an effective procedure for elderly patients. It can improve their quality of life and functionality while reducing the direct costs associated with arthritis. With increased THA procedures being performed on patients of different ages, it is essential to identify factors that may affect mortality for better patient care. Objective: This study aimed to identify the early mortality rate and potential risk factors among patients undergoing primary total hip replacement (THR) at a tertiary hospital in Tanzania. Methodology: This was a retrospective cohort study conducted from January 2020 to December 2021, which involved patients who had undergone THR. Result: The study involved 183 participants, 53.6% of which were male with a mean age of 55.9 ± 18.4 years. Early mortality (death before 3 months) was found to be 7%. Having hypertension and being seropositive for HIV were independent prognostic factors for survival. Hypertension was associated with an increased chance of death by 4.8 times. The likelihood of death was eleven times higher among participants who were HIV+. Conclusion: Hypertensive patients had an increased chance of death of five times more compared to those with no hypertension. HIV+ patients had an increased chance of death, up to eleven times higher with difference in disease profiles and HIV endemicity in our settings this calls for a different approach to THR.

Thirty-Day Morbidity and Mortality After Total Knee Replacement in a Tertiary Care Hospital in Pakistan

Background Total knee arthroplasty has become very popular globally as a safe surgical modality for relieving pain and improving functional outcomes in patients who fail to respond to conservative treatments; however, it may be associated with postoperative complications. The aim of this study is to determine the incidence of postoperative complications occurring within the first 30 days after total knee replacement (TKR). Materials and methods This is a prospective cross-sectional study. All consecutive patients who underwent primary unilateral or bilateral total knee arthroplasty between November 2020 and July 2021 were included in the study. Patients were followed for a period of 30 days, and postoperative complications (if any) were documented. Continuous variables were expressed as means ± standard deviations. Categorical variables were expressed as frequency and percentages, and chi-square test was used to compare the qualitative variables. Univariate and multiple logistic regression analyses were done to analyze the magnitude of associations of the complication with other predictor variables keeping a level of significance of <0.05. Results The overall complication rate within the 30-day window was 7.0%. Postoperative surgical site infections (SSI) were noted in three patients (2.6%). Thromboembolic complications were seen in only one patient (0.9%). One patient (0.9%) was readmitted within the one-month period after initial discharge, and one patient (0.9%) expired within 12 hours postoperatively. Conclusion TKR renders satisfactory results with a low incidence of complications in general; however, wound infections, thromboembolic complications, and cardiovascular complications do occur postoperatively. Male gender, obesity, and bilateral TKRs remain the notable risk factors for the development of complications post-procedure.

Prognostic Factors of Clinical and Economic Outcomes of Hip Arthroplasty in a Developing Country: A Multilevel Analysis with a 4-Year Cohort Study

INTRODUCTION

This study is aimed at estimating the 30-day postoperative mortality rate and total costs of the medical episode, as well as determining prognostic factors associated with these outcomes for adult patients who have undergone total hip arthroplasty (THA) in Colombia's contributory health system.

METHODS

This was a retrospective cohort using administrative data and included adult patients enrolled in Colombia's contributory health system who underwent THA between the years 2011 and 2014. Outcomes were 30-day mortality ICU admissions, and the 1-year rate of fractures and revisions as well as the total cost of the medical episode incurred by the third-payer for 90 days following the procedure. Multilevel linear regression models were also generated to determine the prognostic factors associated with the outcomes presented.

RESULTS

The study included 17,289 patients, with an average age of 67 years. Outcome rates were calculated per 100 surgeries, resulting in 2.15 for mortality, 3.41 for ICU admissions, 2.42 for revision hip arthroplasty and 0.62 for periprosthetic fractures. This study found the age and Charlson Comorbidity Index were associated with mortality and complications, and that being female and performing the procedure in the capital city were protective factors. It also found that the median total cost of the medical episode was USD $ USD$2742.161 (p25-p75: 353.092-3291.747). The multivariate model found increasing trends in cost as age and CCI scores rose, and higher costs in the Atlantic region.

CONCLUSIONS

Colombia has higher rates of complications from THA than other countries but lower health system costs. For these patients, age, CCI and the geographic region are factors that are associated with mortality, complications, and health system costs.

Understanding the 30-day mortality burden after revision total knee arthroplasty

Background

In revision total knee arthroplasty (TKA), information regarding perioperative mortality risk is essential for careful decision-making. This study aimed to elucidate the (1) overall 30-day mortality rate and (2) 30-day mortality rate stratified by age, comorbidity, and septic vs aseptic failure after revision TKA.

Methods

The American College of Surgeons National Surgical Quality Improvement Program was reviewed for all patients undergoing revision TKA from 2011 to 2019. A total of 32,354 patients who underwent TKA were identified and categorized as mortality (n = 115) or mortality-free (n = 32,239). Patient characteristics were compared between cohorts and further stratified by septic and aseptic failure.

Results

The overall 30-day mortality rate was 0.36%. The percentage of deaths per age group (normalized per 1000) was 0% (18-29 years), 0% (30-39 years), 0.18% (40-49 years), 0.13% (50-59 years), 0.14% (60-69 years), 0.40% (70-79 years), 1.25% (80-89 years), and 6.93% (90+ years). The percentage of deaths per American Society of Anesthesiologists (ASA) class was 0.30% (ASA 1), 0.06% (ASA 2), 0.39% (ASA 3), 2.41% (ASA 4), and 14.29% (ASA 5). Septic revision (P < .001), general anesthesia (P < .001), body mass index ≤ 24.9 (P < .001), and insulin-dependent diabetes (P = .039) were associated with an increased risk of mortality.

Conclusions

Increasing age, greater comorbidity burden, underweight or normal body mass index, insulin-dependent diabetes, septic revision, and general anesthesia were all associated with an increased risk of mortality after revision TKA. Notably, 1 in 80 patients aged 80-89 years died after revision TKA compared to 1 in 720 patients aged 60-69 years. Patients who underwent septic revision had a 4-fold increase in mortality compared to aseptic revision. Our stratified assessment of mortality provides a more individualized estimation of risk that can be used for patient counseling in revision TKA.

Incidence and risk factors analysis for mortality after total knee arthroplasty based on a large national database in Korea

This study aimed to analyze the rates and risk factors of postoperative mortality among 560,954 patients who underwent total knee arthroplasty (TKA) in Korea. The National Health Insurance Service-Health Screening database was used to analyze 560,954 patients who underwent TKA between 2005 and 2018. In-hospital, ninety-day, and one-year postoperative mortality, and their association with patient’s demographic factors and various comorbidities (ie., cerebrovascular disease, congestive heart failure, and myocardial infarction) were assessed. In-hospital, ninety-day and one-year mortality rates after TKA were similar from 2005 to 2018. The risk of in-hospital mortality increased with comorbidities like cerebrovascular disease (hazard ratio [HR] = 1.401; 95% confidence interval [CI] = 1.064–1.844), congestive heart failure (HR = 2.004; 95% CI = 1.394 to 2.881), myocardial infarction (HR = 2.111; 95% CI = 1.115 to 3.998), and renal disease (HR = 2.641; 95% CI = 1.348–5.173). These co-morbidities were also independent predictors of ninety-day and one-year mortality. Male sex and old age were independent predictors for ninety-day and one-year mortality. And malignancy was risk factor for one-year mortality. The common preoperative risk factors for mortality in all periods were male sex, old age, cerebrovascular disease, congestive heart failure, myocardial infarction, and renal disease. Malignancy was identified as risk factor for one-year mortality. Patients with these comorbidities should be provided better perioperative care.

Complications to 6 months following total hip or knee arthroplasty: observations from an Australian clinical outcomes registry

Background

Total hip and total knee arthroplasty (THA/TKA) are increasing in incidence annually. While these procedures are effective in improving pain and function, there is a risk of complications.

Methods

Using data from an arthroplasty registry, we described complication rates including reasons for reoperation and readmission from the acute period to six months following THA and TKA in an Australian context. Data collection at 6 months was conducted via telephone interview, and included patient-reported complications such as joint stiffness, swelling and paraesthesia. We used logistic regression to identify risk factors for complications.

Results

In the 8444 procedures included for analysis, major complications were reported by 9.5 and 14.4% of THA and TKA patients, respectively, whilst minor complications were reported by 34.0 and 46.6% of THA and TKA patients, respectively. Overall complications rates were 39.7 and 53.6% for THA and TKA patients, respectively. In THA patients, factors associated with increased risk for complications included increased BMI, previous THA and bilateral surgery, whereas in TKA patient factors were heart disease, neurological disease, and pre-operative back pain and arthritis in a separate joint. Female gender and previous TKA were identified as protective factors for minor complications in TKA patients.

Conclusion

We found moderate rates of major and high rates of minor postoperative complications following THA and TKA in Australia and have identified several patient factors associated with these complications. Efforts should be focused on identifying patients with higher risk and optimising pre- and post-operative care to reduce the rates of these complications.

Effects of body weight support and gait velocity via antigravity treadmill on cardiovascular responses early after total knee arthroplasty

To investigate the effects of body weight support (BWS) and gait velocity on cardiovascular responses during walking on an antigravity treadmill early after unilateral and bilateral total knee arthroplasty (TKA).This study was a cross-sectional study design. Fifty patients (7 males and 43 females; average age, 72.0 ± 5.1 years) at 4 weeks after unilateral (n = 25) and bilateral (n = 25) primary TKA were enrolled in the study. Subjects walked on an antigravity treadmill at speeds of 2.5 km/hour and 3.5 km/hour with 3 levels (50%, 25%, and 0%) of BWS. Cardiovascular responses were monitored by measuring oxygen consumption (VO2), heart rate (HR), systolic and diastolic blood pressure (SBP/DBP), the respiratory exchange ratio (RER), and rate pressure product (RPP). Borg rating of perceived exertion (RPE) and a visual analog scale (VAS) of knee pain were recorded immediately after each trial.There were no significant differences in cardiovascular responses between the unilateral and bilateral TKA groups. In the repeated measures Analysis of Variance, VO2 levels, HR, RPP, RPE, RER, and VAS were significantly increased in proportion to 3 levels (50%, 25%, and 0%) of BWS for unilateral and bilateral TKA groups, respectively. Meanwhile, SBP and DBP were unaffected by differences in BWS. At 3.5 km/hour, VO2, RPE, and RER values were statistically greater than those at 2.5 km/hour under the same BWS conditions.We found that the reduction in the metabolic demand of activity, coupled with positive pressure on the lower extremities, reduced VO2 and HR values as BWS increased.Cardiovascular responses vary according to BWS and gait velocity during antigravity treadmill walking. BWS rather than gait velocity had the greatest effect on cardiovascular responses and knee pain.

Perioperative morbidity in total knee arthroplasty

Introduction

As the life expectancy and weight of patients are increasing, more old and obese patients are undergoing total knee arthroplasty (TKA). TKA may lead to several perioperative complications. These include anesthesia-related risks, exacerbation of comorbid medical issues and complications of surgical procedure. We have no studies reporting medical complications following TKA among our population. This study aimed to evaluate perioperative complications of TKA and to identify the related risk factors.

Methods

It was a monocentric retrospective including 410 observations in the local TKA registry. Data of patients operated for primary unilateral TKA during the period from January 2014 to December 2017 were reviewed. All patients had standardized protocols of anesthesia and post operative care for three days following surgery. Multivariate logistic regression was used to identify the predicting factors for complications.

Results

Incidence of perioperative complications was 37.1%. The most frequent were per operative hypotension (14.1%) and postoperative desaturation (21.7%, including pulmonary embolism in 2.4%). Multivariate logistic regression analysis identified: age ≥ 65 years (OR=1.9; p=0.006), respiratory diseases (OR=1.8; p=0.042) and general anesthesia (OR=2.8; p=0.009) as significant risk factors for any complications. Loss of autonomy (OR=4.8; p <0.001) and general anesthesia (OR=2.6; p=0.03) were significant risk factors for hypotension. Age ≥ 65 years (OR=2.6;p<0.001), female gender (OR=4.3;p=0.006) and respiratory diseases(OR=1.9;p=0.02) were associated with postoperative desaturation.

Conclusion

This study highlighted hemodynamic and respiratory complications as the most common early complications in TKA. Age ≥ 65years, general anesthesia and respiratory diseases were significant risk factors.

Predictive Factors for Developing Chronic Pain After Total Knee Arthroplasty

Total knee arthroplasty offers substantial improvements for patients as measured by functional status and quality of life; however, 8% to 34% of patients experience chronic postsurgical pain following surgery (CPSP). In addition to disruption in daily activities of life caused by the pain itself, CPSP has been associated with an overall reduction in quality of life following surgery. Risk factors for CPSP can be broadly defined as potentially modifiable or unlikely modifiable. Unlikely modifiable risks include gender, age, medical comorbidities, and socioeconomic status. Potentially modifiable risks include perioperative pain, physical function, psychological state, surgical factors, and possibly genomics. Understanding risks and the magnitude of their effect on outcomes such as CPSP is desirable because interventions designed to affect these factors may be able to dramatically improve outcomes.

Mortality After Total Knee Arthroplasty: A Systematic Review of Incidence, Temporal Trends, and Risk Factors

BACKGROUND

The capacity for total knee arthroplasty to improve pain, quality of life, and functional outcomes is widely recognized. Postoperative mortality is rare but of paramount importance, and needs to be accurately quantified and conveyed to patients in order to support decision-making prior to surgery. The purpose of this study was to determine a contemporary estimate of the risk of mortality following total knee arthroplasty, including the identification of temporal trends, common causes, and modifiable and nonmodifiable risk factors.

METHODS

We performed a systematic review with searches of MEDLINE, AMED, CAB Abstracts, and Embase. Studies in any language published from 2006 to 2016 reporting 30 or 90-day mortality following total knee arthroplasty were included, supplemented by contact with authors. Meta-analysis and meta-regression were performed for quantitative data.

RESULTS

Thirty-seven studies with mortality data from 15 different countries following over 1.75 million total knee arthroplasties formed the basis of this review. The pooled Poisson-normal random-effects meta-analysis estimates of 30 and 90-day mortality were 0.20% (95% confidence interval [CI], 0.17% to 0.24%) and 0.39% (95% CI, 0.32% to 0.49%). Both estimates have fallen over the 10-year study period (p < 0.001). Meta-regression using the median year of surgery as a moderator showed that 30 and 90-day mortality following total knee arthroplasty fell to 0.10% (95% CI, 0.07% to 0.14%) and 0.19% (95% CI, 0.15% to 0.23%), respectively, in 2015. The leading cause of death was cardiovascular disease.

CONCLUSIONS

There is an ongoing worldwide temporal decline in mortality following total knee arthroplasty. Improved patient selection and perioperative care and a healthy-population effect may account for this observation. Efforts to further reduce mortality should be targeted primarily at reducing cardiovascular events following total knee arthroplasty.

LEVEL OF EVIDENCE

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

Thirty-day mortality following total knee arthroplasty over 7 years at a tertiary referral centre of orthopaedic excellence

Total Knee Arthroplasty (TKA) is one of the most successful orthopaedic procedures. Around 100,000 TKAs are performed yearly in the United Kingdom. The aim of this study was to report the mortality rate within 30 days after a TKA in an Orthopaedic Centre of Excellence. We reviewed prospectively collected data of 7067 TKAs performed between April 2009-November 2016. All mortalities within 30 days of a TKA were recorded. Data such as age, sex, ASA, comorbidities and cause of death was recorded. There were 14 (0.198%) deaths within 30 days of TKA. There were eight male patients and six female patients who died. No statistical difference was demonstrated between gender. (p = 0.37). The mean age was 77.9 years (66-94 years). Means days to death from post-op were 9.6 days (2-30 days). One patient was ASA 1, six patients were ASA 2, six patients were ASA 3 and one patient did not have an ASA recorded. There was no statistical difference between the difference ASA groups. (p = 0.27). Cause of death documented was as follow: acute left ventricular failure-3; myocardial infarction-2; pneumonia-2; pulmonary oedema-1; gastrointestinal bleed-1 and multiorgan failure-1. Four patients did not have their cause of death recorded. The 30-day mortality rate after TKA in our institute is low and is comparable to other institutes. This emphasizes that primary TKA is a safe procedure. The predominant cause of perioperative mortality is cardiopulmonary disease.

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.