Thromb Haemost 2019; 119(04): 668-674
DOI: 10.1055/s-0039-1677732
Stroke, Systemic or Venous Thromboembolism
Georg Thieme Verlag KG Stuttgart · New York

Reduction in Mortality following Elective Major Hip and Knee Surgery: A Systematic Review and Meta-Analysis

Ke Xu
1  Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
2  Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
3  Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
,
Noel C. Chan
4  Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
5  Department of Medicine, McMaster University, Hamilton, Ontario, Canada
,
Quazi Ibrahim
1  Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
,
Paul Kruger
1  Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
,
Smita Sinha
1  Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
,
Vinai Bhagirath
1  Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
5  Department of Medicine, McMaster University, Hamilton, Ontario, Canada
,
Jeffrey Ginsberg
5  Department of Medicine, McMaster University, Hamilton, Ontario, Canada
,
Shrikant Bangdiwala
1  Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
5  Department of Medicine, McMaster University, Hamilton, Ontario, Canada
6  Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
,
Gordon Guyatt
5  Department of Medicine, McMaster University, Hamilton, Ontario, Canada
,
John Eikelboom
1  Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
5  Department of Medicine, McMaster University, Hamilton, Ontario, Canada
,
Jack Hirsh
5  Department of Medicine, McMaster University, Hamilton, Ontario, Canada
› Author Affiliations
Further Information

Publication History

30 September 2018

17 December 2018

Publication Date:
30 January 2019 (eFirst)

Abstract

Background Systematic reviews reporting time trends in mortality following major orthopaedic surgery are few and have limitations. They reported on only a fraction (< 15%) of the available data and did not investigate potential causes of the reduction in mortality.

Methods We searched PubMed for randomized trials and observational studies, published between 1950 and 2016, reporting on mortality within 3 months of elective total hip and knee replacement (THR/TKR). Mortality risks were estimated for each 5-year interval using a Poisson regression model and presented by study design and mode of prophylaxis. To estimate the mortality reduction unrelated to anti-thrombotic use, we performed a pooled analysis of four thromboprophylaxis strategies for which data spanned five decades.

Results We identified 255 eligible studies, which documented 31,604 deaths among 6,293,954 patients, and found a consistent decline in mortality irrespective of study design and mode of prophylaxis. Mortality declined from 1.15% pre-1980 to 0.24% post-2000, a 78.7% relative risk reduction (95% confidence interval [CI]: 74.7–82.1%) in randomized and cohort studies. Furthermore, our data showed a 74.4% (95% CI: 68.7–79.0%) relative reduction in mortality independent of the methods of prophylaxis, thereby indicating that improvements in peri-operative care unrelated to anti-thrombotic prophylaxis played a major role in such reduction.

Conclusion Mortality following elective THR/TKR has markedly declined over the past 50 years and is now low irrespective of which prophylactic agent is being used. Although anti-thrombotic prophylaxis may have contributed, other improvements in peri-operative care played a major role in the mortality reduction.

Supplementary Material