The study prospectively collected data on systemic and local complications from 15,383 joint arthroplasty procedures performed over 6 years. There were 486 major systemic complications, most commonly pulmonary embolism (152 cases), tachyarrhythmia (92), and acute myocardial infarction (36). There were also 109 major local complications, including 16 vascular injuries and 29 peripheral nerve injuries. The incidence of complications was higher after knee arthroplasty, bilateral procedures, and revision surgery. This study provides baseline data on the range and frequency of potential in-hospital complications following elective joint arthroplasty.

1. The Journal of Arthroplasty Vol. 23 No. 6 Suppl. 1 2008
In Hospital Complications After
Total Joint Arthroplasty
Luis Pulido, MD, Javad Parvizi, MD, Margaret Macgibeny, BS, Peter F. Sharkey, MD,
James J. Purtill, MD, Richard H. Rothman, MD, PhD, and William J. Hozack, MD
Abstract: Total joint arthroplasty is a safe and successful procedure. However,
numerous complications may present after elective arthroplasty. This study
prospectively collected data on systemic and local in hospital complications after
15 383 joint arthroplasties, which included 8230 total hip arthroplasties and 7153
total knee arthroplasties. In general, the incidence of complications was higher after
knee arthroplasty, simultaneous bilateral surgery, and revision surgery. There were
22 (0.16%) deaths in this cohort. We identified 486 major systemic complications,
the most common was pulmonary embolism (152), followed by tachyarrhythmia
(92) and acute myocardial infarction (36). There were 109 major local complications,
including 16 vascular injuries, 29 peripheral nerve injuries, 25 periprosthetic
fractures, and 18 dislocations. Total joint arthroplasty, despite its success, can be
associated with rare serious and life-threatening complications. This study provides a
baseline of complications that can occur after elective joint arthroplasty. Key words:
in hospital complications, systemic, local.
© 2008 Published by Elsevier Inc.
Total joint arthroplasty (TJA) is a successful procedure that elective joint arthroplasty [3,4]. However, because of the
improves the quality of life and function of patients advances in preventive medicine and the marvel of
affected by arthritis of the hip and knee. Although modern medical care, resulting in better survivorship of
considered a safe elective surgery, rare complications can patients, joint arthroplasty is being performed in older
jeopardize the outcome of arthroplasty and, at worst, lead and sicker patients [5-7]. Furthermore, because preva-
to demise of patients [1-4]. lence of osteoarthritis increases with age [8], the higher
The recent improvements in the surgical techniques life expectancy and the upcoming massive cohort from
have contributed to a marked reduction in mortality after the “old baby boomers” will lead to higher number of
joint arthroplasties being performed. The progressive
increase in the number of arthroplasties per year has
already been witnessed in the United States during the
From the Rothman Institute of Orthopaedics at Thomas Jefferson 1990s and the first years of this decade [9]. By the year
University, Philadelphia, Pennsylvania.
Submitted November 21, 2007; accepted May 11, 2008. 2030, the projected demand for primary total hip and
Each author certifies that their institution has approved the knee arthroplasties (THA and TKA, respectively) in the
human protocol for this investigation and that all investigations United States is estimated to increase by 174% to 572 000
were conducted in conformity with ethical principles of research. and by 673% to 3.48 million, respectively [10]. It is,
Benefits or funds were received in partial or total support of the hence, plausible that a higher incidence of medical
research material described in this article. These benefits or support
were received from the following sources: JP, PFS, WJH, and RHR complications in this growing joint arthroplasty popula-
received funding from Stryker Orthopaedics (Mahwah, NJ, USA). tion will be observed.
Reprint requests: Javad Parvizi, MD, Rothman Institute of The latter, if true, would imply that better preoperative
Orthopedics at Thomas Jefferson Hospital, 925 Chestnut Street, medical optimization and strict postoperative surveillance
Philadelphia, PA 19107.
© 2008 Published by Elsevier Inc. of these patients are required. This study was designed to
0883-5403/08/2306-0025$34.00/0 elucidate the incidence, timing, and severity of the early
doi:10.1016/j.arth.2008.05.011 complications that occur in the hospital setting after TJA.
139

2. 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 of
every 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 administered
The period of study was from January 2000 to August preoperatively and for 24 hours after the surgery. All
2006; 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 an
and 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 were
were 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, Doppler
during the patient's hospitalization. Most of the compli- sonogram, or computerized tomography were ordered as
cations identified were captured from the resident's necessary by the caring physician.
worksheets from the joint arthroplasty service and
entered into the database. The electronic medical record
Definition of Complications
of the patients, in particular, the discharge summary, was
also searched to capture any complications that may have Complications included in this study occurred in the
gone 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, the
Joint 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 or
formed by or under close supervision of one arthroplasty medical intervention or if they were deemed to pose a
surgeon. (RHR, WJH, PFS, JJP, and JP performed 95% of threat to patient's 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 in
5% of hip arthroplasties were performed through a direct this study.
anterior approach.) Total knee arthroplasties were per- Myocardial infarction was determined based on the rise
formed 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 in
for 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 pulmonary
all 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 or
administration 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 TJA
Joint 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 28
Knee Revision 645 8 637 653 64 32
Primary arthroplasty 5173 1327 3846 6500 65 32
Total arthroplasty 5818 1335 4483 7153 65 32
Total TJA 13 517 1866 11 651 15 383 63 30

3. In Hospital Complications After Total Joint Arthroplasty Pulido et al 141
Table 2. Incidence of In Hospital Systemic Complications After TJA
Hip arthroplasty Knee arthroplasty
TJA Revision Primary Revision Primary
Procedure No. % No. % No. % No. % No. %
No. of procedures 13 517 1427 6272 645 5173
Major systemic complications 486 3.60% 57 3.99% 127 2.02% 48 7.44% 254 4.91%
Cardiovascular 361 2.68% 41 2.87% 97 1.55% 36 5.58% 187 3.61%
Pulmonary embolism 152 1.12% 13 0.91% 32 0.51% 13 2.02% 94 1.82%
Atrial fibrillation 61 0.45% 6 0.42% 25 0.40% 4 0.62% 26 0.50%
Myocardial infarction 36 0.27% 5 0.35% 10 0.16% 4 0.62% 17 0.33%
Pulmonary edema 27 0.20% 1 0.07% 6 0.10% 5 0.78% 15 0.29%
Arrhythmia 25 0.18% 7 0.49% 7 0.11% 4 0.62% 7 0.14%
Deep venous thrombosis 21 0.16% 5 0.35% 6 0.10% 1 0.16% 9 0.17%
Bradycardia 16 0.12% 0 0.00% 4 0.06% 2 0.31% 10 0.19%
Hypotensive crisis 9 0.07% 2 0.14% 3 0.05% 0 0.00% 4 0.08%
Cardiopulmonary arrest 6 0.04% 1 0.07% 0 0.00% 1 0.16% 4 0.08%
Supraventricular tachycardia 6 0.04% 0 0.00% 4 0.06% 1 0.16% 1 0.02%
Asystole 2 0.01% 1 0.07% 0 0.00% 1 0.16% 0 0.00%
Neurologic 27 0.20% 2 0.14% 9 0.14% 1 0.16% 15 0.29%
Stroke 19 0.14% 2 0.14% 9 0.14% 0 0.00% 8 0.15%
Anoxic brain injury 4 0.03% 0 0.00% 0 0.00% 0 0.00% 4 0.08%
Seizure 4 0.03% 0 0.00% 0 0.00% 1 0.16% 3 0.06%
Pulmonary 24 0.18% 1 0.07% 3 0.05% 4 0.62% 16 0.31%
Respiratory failure 14 0.10% 0 0.00% 1 0.02% 1 0.16% 12 0.23%
Aspiration pneumonitis 8 0.06% 1 0.07% 2 0.03% 1 0.16% 4 0.08%
Pneumothorax 2 0.01% 0 0.00% 0 0.00% 2 0.31% 0 0.00%
Gastrointestinal 11 0.08% 1 0.07% 4 0.06% 0 0.00% 6 0.12%
Gastrointestinal bleed 3 0.02% 0 0.00% 1 0.02% 0 0.00% 2 0.04%
Small bowel obstruction 3 0.02% 0 0.00% 3 0.05% 0 0.00% 0 0.00%
Toxic megacolon 3 0.02% 1 0.07% 0 0.00% 0 0.00% 2 0.04%
Appendicitis 1 0.01% 0 0.00% 0 0.00% 0 0.00% 1 0.02%
Peritonitis 1 0.01% 0 0.00% 0 0.00% 0 0.00% 1 0.02%
Blood/other 63 0.47% 12 0.84% 14 0.22% 7 1.09% 30 0.58%
Acute renal failure 48 0.36% 10 0.70% 12 0.19% 5 0.78% 21 0.41%
Sepsis 7 0.05% 1 0.07% 2 0.03% 0 0.00% 4 0.08%
Bacteremia 3 0.02% 0 0.00% 0 0.00% 1 0.16% 2 0.04%
Fungemia 2 0.01% 1 0.07% 0 0.00% 0 0.00% 1 0.02%
Transfusion-related lung injury 2 0.01% 0 0.00% 0 0.00% 1 0.16% 1 0.02%
Multiorgan failure 1 0.01% 0 0.00% 0 0.00% 0 0.00% 1 0.02%
Minor systemic complications 469 3.47% 63 4.41% 199 3.17% 34 5.27% 176 3.40%
Cardiovascular 116 0.86% 14 0.98% 50 0.80% 2 0.31% 52 1.01%
Angina 43 0.32% 3 0.21% 14 0.22% 2 0.31% 24 0.46%
Sinusal tachycardia 19 0.14% 3 0.21% 9 0.14% 0 0.00% 7 0.14%
Hypotension 54 0.40% 8 0.56% 27 0.43% 0 0.00% 21 0.41%
Neurologic 53 0.39% 10 0.70% 20 0.32% 4 0.62% 19 0.37%
Transient neurologic manifestations 32 0.24% 5 0.35% 14 0.22% 2 0.31% 11 0.21%
Confusion 13 0.10% 3 0.21% 5 0.08% 2 0.31% 3 0.06%
Delirium 8 0.06% 2 0.14% 1 0.02% 0 0.00% 5 0.10%
Pulmonary 55 0.41% 7 0.49% 22 0.35% 2 0.31% 25 0.48%
Atelectasis 35 0.26% 4 0.28% 15 0.24% 1 0.16% 16 0.31%
Pneumonia 20 0.15% 3 0.21% 7 0.11% 1 0.16% 9 0.17%
Gastrointestinal 51 0.38% 6 0.42% 26 0.41% 6 0.93% 13 0.25%
Ileus 31 0.23% 3 0.21% 20 0.32% 3 0.47% 5 0.10%
Clostridium difficile 20 0.15% 3 0.21% 6 0.10% 3 0.47% 8 0.15%
Urinary 194 1.44% 26 1.82% 81 1.29% 20 3.10% 67 1.30%
Urinary tract infection 184 1.36% 25 1.75% 77 1.23% 19 2.95% 63 1.22%
Urinary retention 10 0.07% 1 0.07% 4 0.06% 1 0.16% 4 0.08%
In hospital mortality 22 0.16% 9 0.63% 2 0.03% 4 0.62% 6 0.12%
high probability ventilation perfusion scan. Deep venous Statistical Analysis
thrombosis was diagnosed using Doppler ultrasound.
Persistent wound drainage was defined as any clinically Descriptive statistics and Fisher exact test were used
significant amount of drainage from the wound more for analysis of categorical data. Continuous data were
than 48 hours after the index surgery, which required analyzed using descriptive statistics and nonpaired t test.
further treatment. Univariate regression analysis was performed on risk

4. 142 The Journal of Arthroplasty Vol. 23 No. 6 Suppl 1 September 2008
factors for complications. All analyses were performed laceration were diagnosed. The other patient had a
using 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 in
Incidence 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 considered
minor (Table 2). Major systemic complications were
further categorized into different systems, which included Timing of Complications
cardiovascular, pulmonary, neurologic, gastrointestinal, The timing of complications varied according to the type of
blood, and other. Primary and revision knee arthroplasty surgery. Most of the complications occurred within 4 days of
accounted for most systemic complications (62%, 302/ the index surgery. Complications after primary arthroplasty
486). Most of the life-threatening complications (74%) presented earlier compared with those developing after
were cardiovascular in origin, with symptomatic pulmon- revision arthroplasty. The average length of hospital stay was
ary embolism being the most prevalent complication after 3.8 days (range, 1-106 days). Patients undergoing revision
TJA 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 arthroplasty
were 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 Complications
Incidence 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 arthroplasty
complications (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 significant
local 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 local
cause after knee surgery (82%, 9/11). The other 2 patients complications (P b .0001) (Table 4).
presented with a popliteal artery laceration and eventual
thrombosis. Five vascular complications were identified
Mortality
after hip surgery. Direct arterial laceration was the most
common mechanism of injury during THA (4/5). Three There were 22 in hospital deaths in this cohort of 13 517
femoral 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 Primary
Procedure No. % No. % No. % No. % No. %
No. of procedures 13 517 1427 6272 645 5173
Major 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%

5. 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 complications
Variable No. No. P No. P
Female 6954 260 (53.5%) .123 73 (66%) .09
Male 5114 226 (46.5%) 36 (34%)
Age (y) 64 (13-97) 71 (31-92) .0001 66 (30-91) .464
Height (cm) 169.6 (100.1-234.0) 168.3 (125.3-234.0) .022 168.4 (142.0-190.5) .08
Weight (kg) 85.9 (31.0-240.0) 87.0 (37.6-172.4) .375 83.3 (45.6-163.3) .961
BMI 29.9 (13.2-69.9) 30.7 (11.9-66.1) .135 29.2 (15.5-48.8) .078
Arthroplasty
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 number
incidence of in hospital mortality at 0.5% was higher in of primary and revision arthroplasties will be performed in
the revision arthroplasty group compared with 0.1% in the coming years [9]. The recent advances in the design of
the primary arthroplasty cohort (P b .05). Cardiovascular prosthesis, delivery of surgical care, and anesthesia
complications (such as acute coronary syndrome, pul- techniques have further contributed to the success of
monary 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 deemed
advances in modern orthopedic surgery and continues to inappropriate candidates during the early years of joint
be one of the safest and the most effective surgical arthroplasty. Despite the availability of this surgical
procedures, providing immense relief of pain and procedure to the sick and frail patients, the mortality
improvement in function for a large number of patients and morbidity after TJA remains very low [4,12]. Deaths
[2]. Because of the shift toward an elderly society, with a and complications after joint arthroplasty, however, can
Table 5. Intrahospital Mortality After Total Joint Arthroplasty
No. Sex Age (y) Procedure Joint Side Postoperative days Cause of death
1 F 83 Revision Hip Unilateral 0 Acute coronary syndrome
2 M 81 Revision Hip Unilateral 0 Cardiopulmonary arrest
3 M 87 Revision Hip Unilateral 1 Anoxic brain injury, respiratory failure
4 M 65 Revision Hip Unilateral 1 Pulmonary embolism
5 M 81 Revision Knee Unilateral 1 Pulmonary embolism, aspiration pneumonitis
6 F 73 Primary Knee Unilateral 1 Hypotension
7 F 53 Primary Knee Unilateral 1 Pneumothorax
8 M 79 Primary Knee Unilateral 2 Vascular injury
9 F 66 Primary Knee Bilateral 2 Acute coronary syndrome
10 F 80 Primary Hip Unilateral 2 Asystole
11 F 48 Revision Hip Unilateral 2 Ventricular tachyarrhythmia
12 M 73 Revision Hip Bilateral 2 Cardiopulmonary arrest
13 F 64 Revision Knee Unilateral 2 Gastrointestinal bleed, sepsis
14 F 75 Primary Hip Unilateral 2 Cardiopulmonary arrest
15 M 57 Primary Knee Unilateral 4 Respiratory failure
16 F 89 Primary Hip Unilateral 5 Aspiration pneumonia, sepsis
17 M 79 Primary Hip Unilateral 6 Aspiration pneumonia, arrhythmia
18 M 81 Primary Hip Unilateral 6 Acute coronary syndrome, asystole
19 M 74 Primary Hip Unilateral 12 Sepsis
20 F 72 Primary Knee Unilateral 23 Anoxic brain injury, aspiration, pulmonary embolism
21 M 79 Revision Knee Unilateral 34 Massive retroperitoneal hemorrhage
22 F 94 Primary Hip Unilateral 72 Pulmonary embolism, sepsis, respiratory failure
F indicates female; M, male.

6. 144 The Journal of Arthroplasty Vol. 23 No. 6 Suppl 1 September 2008
and do occur [4,13]. This study, designed with the We believe that this prospective study from a single
intention of identifying complications presented in the institution in a relatively large number of patients may
hospital after joint arthroplasty, highlights some impor- serve to provide a baseline of complications that may be
tant findings. First, the study demonstrated that a expected after elective joint arthroplasty.
considerable number of medical complications occur in
up to 4.4% of the joint arthroplasty patients. All these
complications were deemed to be life threatening because References
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