140 The Journal of Arthroplasty Vol. 23 No. 6 Suppl 1 September 2008 Materials and Methods continued for 6 weeks aiming for an international normalized ratio of 1.5 to 2.0. All knee patients also A prospective database collected daily information on received 1000 U of intravenous heparin before inflation ofevery patient undergoing elective joint arthroplasty at our tourniquet during knee arthroplasties. Intravenous anti-institution. This study did not include patients receiving biotics, namely, first-generation cephalosporin, or vanco-partial joint arthroplasties or nonarthroplasty procedures. mycin for those with allergy, were administeredThe period of study was from January 2000 to August preoperatively and for 24 hours after the surgery. All2006; during this time, 15 383 hip and knee arthroplasties patients were mobilized early in the postoperative period,were performed in 13 517 patients, 5728 of whom were either the day of surgery or the next morning.men who had a mean age of 61 years (range, 15-93 years) All patients in this cohort were followed closely by anand 7789 were women who had a mean age of 65 years internist. Patient monitoring of respiratory rate, heart(range, 13-97 years) (Table 1). rate, blood pressure, and pulse oximetry were carried out All patients in this cohort undergoing elective arthro- at frequent intervals (every 6 hours) by the nursing staff.plasty received preoperative medical evaluation and Daily laboratory tests including complete blood count,clearance for surgery. The hospital course of the patients renal function test, blood chemistry, prothrombin time,was followed very closely, and any complications and international normalized ratio were also performed.identified by the caring internist or orthopedic resident Any abnormal changes in these parameters that werewere recorded. A full-time research fellow was dedicated deemed to be clinically significant were further investi-to this study. During this study, there were 2 different gated. Additional tests such as the liver function test,approaches to capture the complications that present troponins, chest radiographs, electrocardiogram, Dopplerduring the patients hospitalization. Most of the compli- sonogram, or computerized tomography were ordered ascations identified were captured from the residents necessary by the caring physician.worksheets from the joint arthroplasty service andentered into the database. The electronic medical record Definition of Complicationsof the patients, in particular, the discharge summary, wasalso searched to capture any complications that may have Complications included in this study occurred in thegone undetected using the first method. hospital before discharge. The complications were cate- Hypotensive regional anesthesia was used for all gorized into systemic (medical) and local (orthopedic)patients unless contraindicated or unsuccessful to achieve. according to the nature of the event. Furthermore, theJoint arthroplasty was carried out in a laminar flow room complications were subcategorized into major and minor,with all members of the surgical team wearing body depending on their severity. Complications were con-exhaust suits during surgery. All operations were per- sidered major if they required complex surgical orformed by or under close supervision of one arthroplasty medical intervention or if they were deemed to pose asurgeon. (RHR, WJH, PFS, JJP, and JP performed 95% of threat to patients life or result in functional impairment.the operations included during the study period.) Minor complications were those that necessitated addi- Most hip arthroplasties were performed in supine tional observation or required medical treatment. Post-position through an anterolateral approach. (Fewer than operative anemia was not included as a complication in5% of hip arthroplasties were performed through a direct this study.anterior approach.) Total knee arthroplasties were per- Myocardial infarction was determined based on the riseformed under tourniquet using medial parapatellar in the troponins levels and/or electrocardiogram changes.arthrotomy approach. Cementless prostheses were used Acute renal failure was defined as an abrupt decline infor the hip arthroplasty cases, and cemented fixation was renal function parameters with reduced urine output.used for total knee cases. Pulmonary embolus was diagnosed based on radiologic Multiple standardized protocols were implemented for tests, namely, the presence of emboli in the pulmonaryall patients. The prophylactic anticoagulation regimen was vasculature using multidetector computerized tomogra-the same throughout the study period. This consisted of phy, and for the patients with chronic renal failure oradministration of warfarin on the day of surgery and allergies to contrast agents, the diagnosis was based on a Table 1. Demographic Distribution of the Patients Undergoing TJAJoint Procedure Patients (no.) Bilateral (no.) Unilateral (no.) Total (no.) Age (mean) BMI (mean)Hip Revision 1427 8 1419 1435 65 28 Primary arthroplasty 6272 523 5749 6795 62 29 Total arthroplasty 7699 531 7168 8230 62 28Knee Revision 645 8 637 653 64 32 Primary arthroplasty 5173 1327 3846 6500 65 32 Total arthroplasty 5818 1335 4483 7153 65 32Total TJA 13 517 1866 11 651 15 383 63 30
142 The Journal of Arthroplasty Vol. 23 No. 6 Suppl 1 September 2008factors for complications. All analyses were performed laceration were diagnosed. The other patient had ausing SPSS version 13 (SPSS, Chicago, Ill). femoral artery thrombosis. Four-compartment fasciotomy was performed in 8 of the 16 patients for compartment syndrome, 5 after TKA and 3 after THA. Results Major complications required further surgical interven- tion, with the exception of peripheral nerve injuries inIncidence of Systemic Complications which a conservative management was elected. Nearly all minor complications were related to the surgical incision, There were a total of 955 (7.1%) systemic complica- the most common of which was wound drainage (2.03%,tions after TJA. Of these, 486 (3.6%) were classified as 274/13 517) (Table 3).major, and the remaining 469 (3.47%) were consideredminor (Table 2). Major systemic complications werefurther categorized into different systems, which included Timing of Complicationscardiovascular, pulmonary, neurologic, gastrointestinal, The timing of complications varied according to the type ofblood, and other. Primary and revision knee arthroplasty surgery. Most of the complications occurred within 4 days ofaccounted for most systemic complications (62%, 302/ the index surgery. Complications after primary arthroplasty486). Most of the life-threatening complications (74%) presented earlier compared with those developing afterwere cardiovascular in origin, with symptomatic pulmon- revision arthroplasty. The average length of hospital stay wasary embolism being the most prevalent complication after 3.8 days (range, 1-106 days). Patients undergoing revisionTJA in this category (1.12% overall incidence). arthroplasty had a longer hospital stay (mean = 5 days for Four hundred sixty-nine minor systemic complications knees and 4 days for hips) than the primary arthroplastywere detected in this cohort. They affected 5 different counterparts (mean = 4 and 3 days, respectively).systems: cardiovascular, pulmonary, neurologic, gastro-intestinal, and urinary (Table 2). Risk Factors for Major ComplicationsIncidence of Local Complications Certain factors were analyzed with respect to their potential influence on the incidence of major systemic and Local complications occurred after 473 arthroplasties local complications. Univariate analysis identified older age(3.5%), of which 109 (0.81%) were deemed to be major (P b .0001), shorter stature (P b .02), revision arthroplastycomplications (Table 3). (P b .0001), knee arthroplasty surgery (P b .0001), and Vascular injuries represented the most feared major simultaneous bilateral procedure (P b .001) to be significantlocal complication. Eleven vascular injuries occurred after predictor of major systemic complications (Table 4). Revi-TKA. Popliteal artery thrombosis was the most common sion arthroplasty was an important predictor of major localcause after knee surgery (82%, 9/11). The other 2 patients complications (P b .0001) (Table 4).presented with a popliteal artery laceration and eventualthrombosis. Five vascular complications were identified Mortalityafter hip surgery. Direct arterial laceration was the mostcommon mechanism of injury during THA (4/5). Three There were 22 in hospital deaths in this cohort of 13 517femoral artery lacerations and one external iliac vessels patients (Table 5), an incidence of 0.16%. Most of deaths Table 3. Incidence of In Hospital Local Complications After TJA Hip arthroplasty Knee arthroplasty TJA Revision Primary Revision PrimaryProcedure No. % No. % No. % No. % No. %No. of procedures 13 517 1427 6272 645 5173Major local complications 109 0.80% 27 1.89% 30 0.48% 9 1.26% 43 0.83%Dislocation 18 0.13% 13 0.91% 4 0.06% 0 0.00% 1 0.02%Periprosthetic fracture 25 0.18% 8 0.56% 8 0.13% 5 0.78% 4 0.08%Deep periprosthetic infection 11 0.08% 3 0.21% 2 0.03% 3 0.47% 3 0.06%Arthrotomy dehiscence 3 0.01% 0 0.00% 0 0.00% 0 0.00% 3 0.06%Peripheral nerve injury 29 0.21% 1 0.07% 12 0.19% 0 0.00% 16 0.31%Vascular injury 16 0.12% 2 0.14% 3 0.05% 1 0.02% 10 0.19%Compartment syndrome 7 0.05% 0 0.00% 1 0.02% 0 0.00% 6 0.12%Minor local complications 364 2.69% 62 4.34% 159 2.54% 42 6.51% 101 1.95%Drainage 274 2.03% 35 2.45% 132 2.10% 33 5.12% 74 1.43%Wound infection 36 0.27% 15 1.05% 10 0.16% 5 0.78% 6 0.12%Hematoma 24 0.18% 9 0.63% 10 0.16% 1 0.16% 4 0.08%Blisters 16 0.12% 0 0.00% 3 0.05% 3 0.47% 10 0.19%Cellulitis 12 0.09% 3 0.21% 4 0.06% 0 0.00% 5 0.10%Decubitus ulcers 2 0.01% 0 0.00% 0 0.00% 0 0.00% 2 0.04%
In Hospital Complications After Total Joint Arthroplasty Pulido et al 143 Table 4. Risk Factors for Major Complications After TJA Without complications Major systemic complications Major local complicationsVariable No. No. P No. PFemale 6954 260 (53.5%) .123 73 (66%) .09Male 5114 226 (46.5%) 36 (34%)Age (y) 64 (13-97) 71 (31-92) .0001 66 (30-91) .464Height (cm) 169.6 (100.1-234.0) 168.3 (125.3-234.0) .022 168.4 (142.0-190.5) .08Weight (kg) 85.9 (31.0-240.0) 87.0 (37.6-172.4) .375 83.3 (45.6-163.3) .961BMI 29.9 (13.2-69.9) 30.7 (11.9-66.1) .135 29.2 (15.5-48.8) .078Arthroplasty Primary 12 770 384 (79%) .0001 77 (71%) .0001 Revision 1947 102 (21%) 32 (29%) Hip 7367 199 (41%) .0001 54 (50.5%) .115 Knee 6740 287 (59%) 55 (49.5%) Bilateral 1761 95 (19.5%) .001 13 (12.1%) .778 Unilateral 11 168 391 (80.5%) 96 (87.9%)(80%) occurred within the first 6 days after surgery. The higher prevalence of osteoarthritis, an increasing numberincidence of in hospital mortality at 0.5% was higher in of primary and revision arthroplasties will be performed inthe revision arthroplasty group compared with 0.1% in the coming years . The recent advances in the design ofthe primary arthroplasty cohort (P b .05). Cardiovascular prosthesis, delivery of surgical care, and anesthesiacomplications (such as acute coronary syndrome, pul- techniques have further contributed to the success ofmonary embolism, fatal arrhythmias, and cardiopulmon- modern-day joint arthroplasty [3,4]. Furthermore, sub-ary arrest) were the most common cause of death. stantial and parallel advances in the medical fields over the recent years have enabled a large number of patients with severe illnesses to enjoy longer life expectancy and seek Discussion orthopedic care for their degenerative joints. Hence, TJA is currently being offered to some patients with serious Total joint arthroplasty represents one of the greatest comorbidities [5,6,11], who may have been deemedadvances in modern orthopedic surgery and continues to inappropriate candidates during the early years of jointbe one of the safest and the most effective surgical arthroplasty. Despite the availability of this surgicalprocedures, providing immense relief of pain and procedure to the sick and frail patients, the mortalityimprovement in function for a large number of patients and morbidity after TJA remains very low [4,12]. Deaths. Because of the shift toward an elderly society, with a and complications after joint arthroplasty, however, can Table 5. Intrahospital Mortality After Total Joint ArthroplastyNo. Sex Age (y) Procedure Joint Side Postoperative days Cause of death1 F 83 Revision Hip Unilateral 0 Acute coronary syndrome2 M 81 Revision Hip Unilateral 0 Cardiopulmonary arrest3 M 87 Revision Hip Unilateral 1 Anoxic brain injury, respiratory failure4 M 65 Revision Hip Unilateral 1 Pulmonary embolism5 M 81 Revision Knee Unilateral 1 Pulmonary embolism, aspiration pneumonitis6 F 73 Primary Knee Unilateral 1 Hypotension7 F 53 Primary Knee Unilateral 1 Pneumothorax8 M 79 Primary Knee Unilateral 2 Vascular injury9 F 66 Primary Knee Bilateral 2 Acute coronary syndrome10 F 80 Primary Hip Unilateral 2 Asystole11 F 48 Revision Hip Unilateral 2 Ventricular tachyarrhythmia12 M 73 Revision Hip Bilateral 2 Cardiopulmonary arrest13 F 64 Revision Knee Unilateral 2 Gastrointestinal bleed, sepsis14 F 75 Primary Hip Unilateral 2 Cardiopulmonary arrest15 M 57 Primary Knee Unilateral 4 Respiratory failure16 F 89 Primary Hip Unilateral 5 Aspiration pneumonia, sepsis17 M 79 Primary Hip Unilateral 6 Aspiration pneumonia, arrhythmia18 M 81 Primary Hip Unilateral 6 Acute coronary syndrome, asystole19 M 74 Primary Hip Unilateral 12 Sepsis20 F 72 Primary Knee Unilateral 23 Anoxic brain injury, aspiration, pulmonary embolism21 M 79 Revision Knee Unilateral 34 Massive retroperitoneal hemorrhage22 F 94 Primary Hip Unilateral 72 Pulmonary embolism, sepsis, respiratory failure F indicates female; M, male.
144 The Journal of Arthroplasty Vol. 23 No. 6 Suppl 1 September 2008and do occur [4,13]. This study, designed with the We believe that this prospective study from a singleintention of identifying complications presented in the institution in a relatively large number of patients mayhospital after joint arthroplasty, highlights some impor- serve to provide a baseline of complications that may betant findings. First, the study demonstrated that a expected after elective joint arthroplasty.considerable number of medical complications occur inup to 4.4% of the joint arthroplasty patients. All thesecomplications were deemed to be life threatening because Referenceslack of emergent intervention could have resulted incatastrophic consequences. Even if one assumes that 1. Coventry MB, Beckenbaugh RD, Nolan DR, et al.emergent medical care could have been provided for 2,012 total hip arthroplasties. A study of postoperativemost of these patients if they were outside the hospital, course and early complications. J Bone Joint Surg Amone cannot overlook the relatively high incidence of 1974;56:273.cardiac serious events that occurred in this patient 2. Kavanagh BF, Dewitz MA, Ilstrup DM, et al. Charnleypopulation. Furthermore, all of the latter occurred despite total hip arthroplasty with cement. Fifteen-yearintensive and rigorous medical evaluation of all the results. J Bone Joint Surg Am 1989;71:1496.patients in this elective joint arthroplasty cohort. Finally, 3. Parvizi J, Holiday AD, Ereth MH, et al. The Frankthis study demonstrated that most of the complications Stinchfield Award. Sudden death during primary hipoccur within the expected typical 4-day hospital stay of a arthroplasty. Clin Orthop Relat Res 1999:39.standard joint arthroplasty. The incidence of in-hospital 4. Parvizi J, Johnson BG, Rowland C, et al. Thirty-daymortality and major complications such as myocardial mortality after elective total hip arthroplasty. J Boneinfarction in this cohort is similar to other reports [12,14]. Joint Surg Am 2001;83-A:1524.Furthermore, patients that developed major medical 5. Kreder HJ, Berry GK, McMurtry IA, et al. Arthro-complications were older (mean = 71 years) compared plasty in the octogenarian: quantifying the risks.with those patients without any complication (mean = 64 J Arthroplasty 2005;20:289.years). Advanced age identified in our study as a 6. Pagnano MW, McLamb LA, Trousdale RT. Primarysignificant risk factor also agrees with the findings of and revision total hip arthroplasty for patients 90previous studies [14,15]. Another important finding of years of age and older. Mayo Clin Proc 2003;78:285.this study is that major systemic complications more 7. Boettcher WG. Total hip arthroplasties in the elderly.frequently presented after bilateral joint arthroplasty. This Morbidity, mortality, and cost effectiveness. Clinfinding is in agreement with previous publications citing a Orthop Relat Res 1992:30.higher postoperative complications after bilateral simulta- 8. Lawrence RC, Helmick CG, Arnett FC, et al. Estimatesneous arthroplasty [16-18]. Although the number of life- of the prevalence of arthritis and selected musculos-threatening complications appears higher in females and keletal disorders in the United States. Arthritis Rheumin obese patients, neither sex nor body mass index (BMI) 1998;41:778.reached statistical significance. Revision arthroplasty was 9. Kurtz S, Mowat F, Ong K, et al. Prevalence of primaryassociated with a longer hospital stay and higher rates of and revision total hip and knee arthroplasty in themajor complications and mortality. These findings were United States from 1990 through 2002. J Bone Jointsimilar to data demonstrated by Mohamed et al  in a Surg Am 2005;87:1487.recent population-based study. 10. Kurtz S, Ong K, Lau E, et al. Projections of primary and There are some caveats to this study. First, this study revision hip and knee arthroplasty in the United Stateswas performed using prospectively collected data from a from 2005 to 2030. J Bone Joint Surg Am 2007;89:780.single, high volume, and specialized joint center where 11. Begg CB, Cramer LD, Hoskins WJ, et al. Impact ofstandardized protocols are in place and patients receive hospital volume on operative mortality for majorthorough preoperative medical evaluation and are fol- cancer surgery. JAMA 1998;280:1747.lowed diligently by internists postoperatively. It is, hence, 12. Mantilla CB, Horlocker TT, Schroeder DR, et al.plausible that the incidence of complications would be Frequency of myocardial infarction, pulmonaryhigher in centers if the aforementioned protocols were embolism, deep venous thrombosis, and death fol-not instituted. Conversely, the implementation of these lowing primary hip or knee arthroplasty. Anesthe-protocols with closer postoperative surveillance, including siology 2002;96:1140.the use of pulse oximetry, and the availability of modern 13. Lie SA, Engesaeter LB, Havelin LI, et al. Earlyimaging modalities such as multidetector CT scan may postoperative mortality after 67,548 total hip replace-have resulted in “overdetection” of complications such as ments: causes of death and thromboprophylaxis in 68pulmonary embolism that may have otherwise gone hospitals in Norway from 1987 to 1999. Acta Orthopunnoticed . Second, extensive effort was made to Scand 2002;73:392.ensure that every complication occurring in the hospital 14. Gill GS, Mills D, Joshi AB. Mortality following primarywas captured. Despite the prospective nature of this total knee arthroplasty. J Bone Joint Surg Am 2003;study, it is possible, though unlikely, that some complica- 85-A:432.tions may have escaped. The latter, if true, would imply 15. Soohoo NF, Lieberman JR, Ko CY, et al. Factorsthat the actual incidence of complications is higher than predicting complication rates following total kneewhat is reported. replacement. J Bone Joint Surg Am 2006;88:480.
In Hospital Complications After Total Joint Arthroplasty Pulido et al 14516. Bullock DP, Sporer SM, Shirreffs Jr TG. Compar- unilateral total knee arthroplasty. J Bone Joint Surg ison of simultaneous bilateral with unilateral total Am 1987;69:484. knee arthroplasty in terms of perioperative compli- 19. Mahomed NN, Barrett JA, Katz JN, et al. Rates and cations. J Bone Joint Surg Am 2003;85-A:1981. outcomes of primary and revision total hip replace-17. Restrepo C, Parvizi J, Dietrich T, et al. Safety of ment in the United States Medicare population. simultaneous bilateral total knee arthroplasty. A J Bone Joint Surg Am 2003;85-A:27. meta-analysis. J Bone Joint Surg Am 2007;89: 20. Parvizi J, Smith EB, Pulido L, et al. The rise in the 1220. incidence of pulmonary embolus after joint arthro-18. Morrey BF, Adams RA, Ilstrup DM, et al. Complica- plasty: is modern imaging to blame. Clin Orthop tions and mortality associated with bilateral or Relat Res 2007;463:107.