While TJA procedures are becoming better managed from a pain and blood loss standpoint, there remains a low, but important risk of mortality inherent in the fact these are large surgical procedures in a relatively old patient population.
Courtney et al. examined 1,012 patients undergoing primary THA or TKA and found that 84% of medical complications occurred within 24 hours postop and 90% occurred within 4 days. These patients had higher incidence of major comorbidities such as CHF, CAD, COPD, and liver failure. Older age was an additional risk factor [1]. In contrast however, a similar study that examined the timing of major postoperative complications found that over 90% occurred within the first 4 days of surgery yet almost 60% of cases occurred in patients without significant comorbidities [2]. Overall, it appears that cardiac failure was the most common cause of mortality, pulmonary embolism was the second.
Identifying patient risk factors is an important part of pre-operative preparation for TJA. Large national databases have been used recently to further identify risk factors for medical complications.
Age (>80), diabetes, BMI > 40, and ASA class (>3, indicator of comorbidities) were all associated with increased risk of 30 day morbidity and mortality after TKA [3]. Age and cardiac disease were associated with 30 day risk in THA [4]. Looking specifically at cardiac complications, hypertension and coronary artery disease comorbities as well as age > 80 were risk factors.[5].
These studies highlight the importance of preoperative screening to identify the risk factors that place a patient at risk for medical complications in the acute postoperative period and require hospital monitoring.
Medical complications are also associated with hospital readmission.
REFERENCES
1. Courtney, P.M., et al., Who Should Not Undergo Short Stay Hip and Knee Arthroplasty? Risk Factors Associated With Major Medical Complications Following Primary Total Joint Arthroplasty. J Arthroplasty, 2015. 30(9 Suppl): p. 1-4.
2. Parvizi, J., et al., Total joint arthroplasty: When do fatal or near-fatal complications occur? J Bone Joint Surg Am, 2007. 89(1): p. 27-32.
3. Belmont, P.J., Jr., et al., Thirty-day postoperative complications and mortality following total knee arthroplasty: incidence and risk factors among a national sample of 15,321 patients. J Bone Joint Surg Am, 2014. 96(1): p. 20-6.
4. Belmont, P.J., Jr., et al., Morbidity and mortality in the thirty-day period following total hip arthroplasty: risk factors and incidence. J Arthroplasty, 2014. 29(10): p. 2025-30.
5. Belmont, P.J., Jr., et al., Postoperative myocardial infarction and cardiac arrest following primary total knee and hip arthroplasty: rates, risk factors, and time of occurrence. J Bone Joint Surg Am, 2014. 96(24): p. 2025-31.