Risk Factors for Early Mortality Following Modern Total Hip Arthroplasty

doi:10.1016/j.arth.2012.06.040

The Journal of Arthroplasty

Volume 28, Issue 3, March 2013, Pages 517-520

https://doi.org/10.1016/j.arth.2012.06.040 Get rights and content

Abstract

The aim of this study was to evaluate the incidence of early mortality and identify risk factors for early death following modern uncemented THA. Between 2000 and 2006, we identified patients who died within 90 days of THA. Demographics, comorbidities, laboratory studies, and complications were analyzed as risk factors for mortality. 38 of 8261 patients undergoing THA (0.46%) died within 90 days postoperatively. Of these, 26% were due to myocardial infarction. Multivariate analysis revealed Charlson index > 3, peripheral vascular disease, elevated postoperative glucose, and abnormal postoperative cardiac studies as independent predictors of early mortality following THA. Caution should be taken in patients with increased comorbidities, PVD, perioperative hyperglycemia, and impaired renal function in order to reduce mortality following THA.

Section snippets

Study Design

After obtaining approval from the Institutional Review Board, the electronic institutional database was retrospectively queried and all patients undergoing THA at our institution from May 1, 2000 until July 1, 2006 were identified. Patients receiving partial hip arthroplasty were excluded from this study. The institutional electronic medical record, the Centers for Disease Control's National Death Index, as well as the Social Security Death Index were used to establish patient survivorship.

Results

The overall ninety-day mortality rate in this series was 0.46% (38/8261). Myocardial infarction accounted for 26% (10/38) of early mortality cases (Table 3). The incidence of fatal pulmonary embolism in our series was 0.048% (4/8261). The mean time to death following THA was 40.5 days (range: 0–85 days). Postmortem examination was performed in only two cases.

Univariate analysis of risk factors for early mortality found that increased age, ASA score greater than three, Charlson Index greater than

Discussion

An important observation of this study was that early mortality following THA has remained low, with an overall mortality rate of 0.46%, despite being performed in older patients with multiple medical comorbidities [4]. In addition, the study identified a number of modifiable risk factors for early mortality; addressing these risk factors prior to surgery may impact the mortality rates following THA in the future. The study also found that myocardial infarction was the most common cause of

References (15)

P. Paavolainen et al.
Causes of death after total hip arthroplasty: a nationwide cohort study with 24,638 patients
J Arthroplasty
(2002)
H.J. Kreder et al.
Arthroplasty in the octogenarian: quantifying the risks
J Arthroplasty
(2005)
S.G. Memtsoudis et al.
Risk factors for perioperative mortality after lower extremity arthroplasty: a population-based study of 6,901,324 patient discharges
J Arthroplasty
(2010)
R. Gandhi et al.
Incidence and timing of myocardial infarction after total joint arthroplasty
J Arthroplasty
(2006)
R.A. Deyo et al.
Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases
J ClinEpidemiol
(1992)
B. Mraovic et al.
Preadmission hyperglycemia is an independent risk factor for in-hospital symptomatic pulmonary embolism after major orthopedic surgery
J Arthroplasty
(2010)
J. Parvizi et al.
Thirty-day mortality after elective total hip arthroplasty
J Bone Joint Surg Am
(2001)

There are more references available in the full text version of this article.

Cited by (39)

Neuraxial Anesthesia Significantly Reduces 30-Day Venous Thromboembolism Rate and Length of Hospital Stay in Primary Total Hip Arthroplasty: A Stratified Propensity Score–Matched Cohort Analysis
2023, Journal of Arthroplasty
General anesthesia (GA) has been the commonly used protocol for total hip arthroplasty (THA); however, neuraxial anesthesia (NA) has been increasingly performed. Our purpose was to compare NA and GA for 30-day postoperative outcomes in United States veterans undergoing primary THA.
A large veteran’s database was utilized to identify patients undergoing primary THA between 1999 and 2019. A total of 56,244 patients had undergone THA and were included in our study. Of these, 44,780 (79.6%) had received GA, and 10,788 (19.2%) had received NA. Patients receiving NA or GA were compared for 30-day mortalities, cardiovascular, respiratory, and renal complications, and wound infections and hospital lengths of stay (LOS). Propensity score matching, multivariate regression analyses, and subgroup analyses by American Society of Anesthesiology classification were performed to control for selection bias and patient baseline characteristics.
Upon propensity-adjusted multivariate analyses, NA was associated with decreased risks for deep venous thrombosis (odds ratio [OR] = 0.63; 95% CI = 0.4-0.9; P = .02), any respiratory complication (OR = 0.63; 95% CI = 0.5-0.9; P = .003), unplanned reintubation (OR = 0.51; 95% CI = 0.3-0.9; P = .009), and prolonged LOS (OR = 0.78; 95% CI = 0.72-0.84; P < .001). Subgroup analyses by American Society of Anesthesiology classes showed NA decreased 30-day venous thromboembolism rate in low-risk (class I/II) patients and decreased respiratory complications in high-risk (class III/IV) patients.
Using a patient cohort obtained from a large national database, NA was associated with reduced risk of 30-day adverse events compared to GA in patients undergoing THA. Postoperative adverse events were decreased with NA administration with similar decreases observed across all patient preoperative risk levels. NA was also associated with a significant decrease in hospital LOS.
What Is the 30-Day Mortality Burden After Elective Total Hip Arthroplasty? An Analysis of 194,062 Patients
2021, Journal of Arthroplasty
Citation Excerpt :
We also found that the largest increase in mortality occurred between CCI scores of 2 and 3, with rates of mortality 4.3 times greater in those patients with a CCI of 3 compared to those with a CCI score of 2. Several other studies have also found a CCI of 2 to be an inflection point [11,13,32,33]. For example, Zeng et al [11] found that, compared to those with a CCI of 2, those with a CCI of 3 or greater had 2.5-fold higher mortality rates.
This study aims to answer the following questions regarding elective total hip arthroplasty (THA): What is (1) the overall 30-day mortality rate; (2) the mortality rate when stratified by age, comorbidities, and preoperative diagnosis; and (3) the distribution of patient demographics, comorbidities, and preoperative diagnoses between the mortality and mortality-free cohorts?
The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all patients undergoing elective primary THA (2011-2018). A total of 194,062 patients were categorized based on the incidence of 30-day mortality (mortality: n = 206 vs mortality-free: n = 193,856). Patient demographics, comorbidities, and preoperative diagnosis (osteoarthritis [OA] vs non-OA) were recorded. Age category, American Society of Anesthesiologists (ASA) score, and modified Charlson Comorbidity Index (CCI) scores were normalized per 1000 and stratified by preoperative diagnosis.
The 30-day mortality rate was 0.11%. The percentage of deaths per age group (normalized per 1000) was 0% (18-29 years), 0% (30-39 years), 0.049% (40-49 years), 0.052%(50-59 years), 0.071% (60-69 years), 0.133% (70-79 years), and 0.352% (80-89 years). The percentage of deaths per ASA score was 0% (ASA I), 0.035% (ASA II), 0.174% (ASA III), and 1.008% (ASA IV). The percentage of deaths per CCI score was 0.09% (CCI = 0), 0.23% (CCI = 1), 0.74% (CCI = 2), 3.21% (CCI = 3), 4.76% (CCI = 4), and 0.57% (CCI ≥ 5). Non-OA diagnoses were significantly more frequent in the mortality cohort (16.0% vs 7.6%; P < .001).
The risk of mortality was highest in patients aged 80-89, patients of ASA class IV, patients with a CCI score of 4, and patients with a non-OA diagnosis. The overall rate of death was higher in the non-OA cohort compared to the OA cohort.
III.
Are We Treating Similar Patients? Hospital Volume and the Difference in Patient Populations for Total Knee Arthroplasty
2020, Journal of Arthroplasty
Citation Excerpt :
Additionally, patients were identified as high risk according to age, BMI, and comorbidities. Patients with CCI scores ≥4 have previously been shown to be at an increased risk for adverse outcomes in total joint arthroplasty [17–19]. Similarly, age >65 years and a BMI >40 (class III obesity) have also been associated with increased rates of complications [20–25].
Early findings of superior total knee arthroplasty (TKA) outcomes at high volume centers have been thought to have led to distinct referral patterns. However, the effect of these selective referral processes has not been well assessed. Therefore, this study compared the characteristics of primary TKA patients at high, intermediate, and low volume hospitals.
A total of 12,541 primary TKA patients were stratified into risk groups based on age (>65 years), body mass index (>40), and Charlson Comorbidity Index (≥4). Hospitals were classified as low, intermediate, or high volume based on mean annual TKA volumes (<250, 250-499, and >500). Multivariate logistic regression models evaluated the relationship between baseline patient characteristics and hospital volume.
There was a greater percentage of high risk patients at high volume (19%, n = 853) compared to those at intermediate (16%, n = 899) or low volume (17%, n = 444) hospitals (P < .001). Patients with a body mass index >40 were more likely to be treated at high compared to intermediate (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.2-1.6, P < .001) and low volume centers (OR 1.4, 95% CI 1.2-1.7, P < .001). Patients with Charlson Comorbidity Index scores ≥4 were also more likely be treated at high compared to intermediate (OR 1.5, 95% CI 1.3-1.6, P < .001) or low (OR 1.2, 95% CI 1.0-1.4, P = .002) volume centers.
This study found that TKA patients at high volume centers have significantly different baseline characteristics compared to those at lower volume centers. This study highlights the importance of considering hospital volume status and the associated disparity in the preoperative risk of patients when comparing primary TKA outcomes between centers.
Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis
2019, British Journal of Anaesthesia
Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes.
The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations.
The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57–0.80/OR: 0.83, 95% CI: 0.60–1.15; pulmonary OR: 0.65, 95% CI: 0.52–0.80/OR: 0.69, 95% CI: 0.58–0.81; acute renal failure OR: 0.69, 95% CI: 0.59–0.81/OR: 0.73, 95% CI: 0.65–0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42–0.65/OR: 0.77, 95% CI: 0.64–0.93; infections OR: 0.73, 95% CI: 0.67–0.79/OR: 0.80, 95% CI: 0.76–0.85; and blood transfusion OR: 0.85, 95% CI: 0.82–0.89/OR: 0.84, 95% CI: 0.82–0.87.
Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation. Recommendation: neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty.
PROSPERO CRD42018099935.
Effect of Antibiotic-Impregnated Bone Cement in Primary Total Knee Arthroplasty
2019, Journal of Arthroplasty
Citation Excerpt :
Additionally, patients were identified as high risk according to age, BMI, and comorbidities. Patients with CCI scores >3 have previously been shown to be at an increased risk for infections and adverse outcomes in TJA [32–34]. Similarly, age >65 years and a BMI >40 have also been associated with increased rates of infections and complications [35–40].
The purpose of this study is to evaluate the effect of commercially available antibiotic-impregnated bone cement (AIBC) on (1) prosthetic joint infections (PJIs) and (2) surgical site infections (SSIs) after primary total knee arthroplasty (TKA).
A review of primary TKAs between 2014 and 2017 from an institutional database was conducted. This identified 12,541 cases which were separated into AIBC (n = 4337) and non-AIBC (8,164) cohorts. Medical records were reviewed for PJIs and SSIs (mean 2-year postoperative period). Infection rates between the cohorts were compared with univariate analyses followed by subanalysis of high risk patients (defined as having 2 or more of the following characteristics: >65 years, body mass index >40, or Charlson Comorbidity Index score >3). To control for confounders, multivariate analyses were performed with regression models adjusted for age, gender, body mass index, comorbidities, year, operative times, and lengths of stay.
On univariate analysis, PJI rates were higher in the AIBC cohort (1.0%) compared to the non-AIBC cohort (0.5%, P < .001). Subanalysis of the high risk patients also showed that PJI rates were higher in the AIBC cohort (1.9% vs 0.6%, P < .01). After adjusting for potential confounders, no significant associations between PJIs and AIBC use were found (odds ratio 1.4, 95% confidence interval 0.9-2.3, P = .133). Similarly, no significant differences in SSI rates were observed between the AIBC (2.9%) and non-AIBC cohorts (2.4%, P = .060) and no significant associations between SSIs and AIBC were found with multivariate analysis (odds ratio 1.0, 95% confidence interval CI 0.8-1.3, P = .948).
This study found that there was no clinically or statistically significant decrease in infection rates with AIBC in primary TKAs.
Predictors of Discharge Disposition Following Laminectomy for Intradural Extramedullary Spinal Tumors
2019, World Neurosurgery
To identify independent risk factors for non-home discharge in patients undergoing laminectomy for intradural extramedullary spinal tumors.
We performed a retrospective cohort analysis of data from the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2014. Adult patients who underwent laminectomy for the excision of intradural extramedullary spinal tumors were included and divided into 2 groups based on home or non-home discharge disposition. We compared baseline patient characteristics, comorbidities, and operative factors between the 2 groups, and then performed multivariate regression analyses to identify independent risk factors for non-home discharge.
A total of 1232 patients were included, of whom 248 (20.1%) were discharged to a non-home facility. Univariate analysis demonstrated that patients discharged to a non-home facility were more frequently aged ≥65 years and American Society of Anesthesiologists classification ≥3 with obesity, diabetes, dyspnea, functional dependence, cardiac comorbidity, renal comorbidity, and anemia. Operative factors correlated with non-home discharge were operative time of ≥4 hours and tumor location in the cervical or thoracic spine. Multivariate regression analysis identified age ≥65 years (odds ratio [OR] 2.73; confidence interval [CI] 1.80–4.13; P < 0.001), American Society of Anesthesiologists classification ≥3 (OR 2.36; CI 1.53–3.65; P < 0.001), dependent functional status (OR 4.30; CI 1.95–9.48; P < 0.001), hospital-acquired conditions (OR 2.32; CI 1.15–4.68; P = 0.019), and prolonged length of stay (OR 4.05; CI 2.72–6.03; P < 0.001) as predictors of non-home discharge.
Early identification of patients at risk for non-home discharge is important in order to implement comprehensive discharge planning protocols that reduce inpatient length of stay, as well as associated complications and costs.

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Risk Factors for Early Mortality Following Modern Total Hip Arthroplasty

Abstract

Section snippets

Study Design

Results

Discussion

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J ClinEpidemiol

J Arthroplasty

Thirty-day mortality after elective total hip arthroplasty

J Bone Joint Surg Am