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J Knee Surg 2023; 36(06): 575-583
DOI: 10.1055/s-0041-1740386
Original Article

Factors Affecting 30-Day Mortality following Primary Elective Total Knee Arthroplasty: A Database Study of 326,157 Patients

Kevin Zhai 
1   Case Western Reserve University School of Medicine, Cleveland, Ohio
,
Melissa Orr
2   Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Daniel Grits
2   Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Ahmed K. Emara
2   Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Christopher A. Rothfusz
1   Case Western Reserve University School of Medicine, Cleveland, Ohio
2   Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
Nicolas S. Piuzzi 
2   Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Abstract

Despite its rarity, the risk of mortality following primary elective total knee arthroplasty (TKA) is a critical component of surgical decision-making and patient counseling. The purpose of our study was to (1) determine the overall 30-day mortality rate for unilateral primary elective TKA patients, (2) determine the 30-day mortality rates when stratified by age, comorbidities, and preoperative diagnosis, and (3) identify the distribution of (i) patient demographics, (ii) baseline comorbidities, and (iii) preoperative diagnoses between mortality and mortality-free cohorts. A total of 326,157 patients underwent primary elective TKA (2011–2018) were identified through retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were divided into 30-day mortality (n = 320) and mortality-free (n = 325,837) cohorts. Patient demographics, preoperative comorbidities, and preoperative diagnoses were compared. Age group, American Society of Anesthesiology (ASA) score, and modified Charlson Comorbidity Index (CCI) scores were normalized per 1000 and stratified by preoperative diagnosis. The overall mortality rate was 0.098%. Older age (p < 0.001) and male gender (p < 0.001) were associated with increased mortality. There was no association between mortality and race (p = 0.346) or body mass index (BMI) class (p = 0.722). All reported comorbidities except smoking status were significantly greater in the mortality cohort (p < 0.05). For ASA scores of I, II, III, and IV, the number of deaths per 1,000 were 0.16, 0.47, 1.4, and 4.4, respectively. For CCI scores of 0, 1, 2, 3, 4, and 6, mortality rates per 1,000 were 0.76, 2.1, 7.0, 11, 29, and 7.6, respectively. Mortality rates for a preoperative diagnosis of osteoarthritis (OA) versus non-OA were, respectively, 0.096% and 0.19% (p < 0.001). Increased age, male gender, increased comorbidity burden, and non-OA preoperative diagnoses are associated with higher rates of 30-day postoperative mortality. There were no significant associations between BMI or race and 30-day mortality. These findings aid in identifying of higher-risk patients, who can then receive appropriate counseling or preoperative interventions to reduce the risk of perioperative mortality.

Keywords

mortality - elective total knee arthroplasty - complications - 30-day mortality - high-risk factors


Publication History

Received: 17 April 2021

Accepted: 22 October 2021

Article published online:
17 December 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Sloan M, Premkumar A, Sheth NP. Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am 2018; 100 (17) 1455-1460
    CrossrefPubMedGoogle Scholar
  • 2 Maradit Kremers H, Larson DR, Crowson CS. et al. Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am 2015; 97 (17) 1386-1397
    CrossrefPubMedGoogle Scholar
  • 3 Klug A, Gramlich Y, Rudert M. et al. The projected volume of primary and revision total knee arthroplasty will place an immense burden on future heath care systems over the next 30 years. Knee Surgery, Sport Traumatol Arthrosc. 2020 DOI: 10.1007/s00167-020-06154-7
    CrossrefPubMedGoogle Scholar
  • 4 Buitrago G, Ortiz JR, Camacho F. Clinical outcomes, health care costs and prognostic factors for total knee arthroplasty: a multilevel analysis of a national cohort study using administrative claims data. J Knee Surg 2020; 1 (212) DOI: 10.1055/s-0040-1715097.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Maempel JF, Riddoch F, Calleja N, Brenkel IJ. Longer hospital stay, more complications, and increased mortality but substantially improved function after knee replacement in older patients. Acta Orthop 2015; 86 (04) 451-456
    CrossrefPubMedGoogle Scholar
  • 6 Harris IA, Hatton A, de Steiger R, Lewis P, Graves S. Declining early mortality after hip and knee arthroplasty. ANZ J Surg 2020; 90 (1-2): 119-122
    CrossrefPubMedGoogle Scholar
  • 7 Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010. JAMA 2012; 308 (12) 1227-1236
    CrossrefPubMedGoogle Scholar
  • 8 Warren JA, Sundaram K, Anis HK, Kamath AF, Higuera CA, Piuzzi NS. Have venous thromboembolism rates decreased in total hip and knee arthroplasty?. J Arthroplasty 2020; 35 (01) 259-264
    CrossrefPubMedGoogle Scholar
  • 9 Whitlock KG, Piponov HI, Shah SH, Wang OJ, Gonzalez MH. Gender role in total knee arthroplasty: a retrospective analysis of perioperative outcomes in US patients. J Arthroplasty 2016; 31 (12) 2736-2740
    CrossrefPubMedGoogle Scholar
  • 10 Chan Y, Selvaratnam V, Raut V. Thirty-day mortality following total knee arthroplasty over 7 years at a tertiary referral centre of orthopaedic excellence. J Clin Orthop Trauma 2018; 9 (01) 51-53
    CrossrefPubMedGoogle Scholar
  • 11 Murphy BPD, Dowsey MM, Choong PFM. The impact of advanced age on the outcomes of primary total hip and knee arthroplasty for osteoarthritis: a systematic review. JBJS Rev 2018; 6 (02) e6 DOI: 10.2106/JBJS.RVW.17.00077.
    CrossrefPubMedGoogle Scholar
  • 12 Murphy BPD, Dowsey MM, Spelman T, Choong PFM. The impact of older age on patient outcomes following primary total knee arthroplasty. Bone Joint J 2018; 100-B (11) 1463-1470
    CrossrefPubMedGoogle Scholar
  • 13 Jauregui JJ, Boylan MR, Kapadia BH, Naziri Q, Maheshwari AV, Mont MA. Total joint arthroplasty in nonagenarians: what are the risks?. J Arthroplasty 2015; 30 (12) 2102-5.e1
    CrossrefPubMedGoogle Scholar
  • 14 Easterlin MC, Chang DG, Talamini M, Chang DC. Older age increases short-term surgical complications after primary knee arthroplasty. Clin Orthop Relat Res 2013; 471 (08) 2611-2620
    CrossrefPubMedGoogle Scholar
  • 15 Sloan M, Lee GC. Mortality and complications in patients with metastatic disease after primary total hip and total knee arthroplasty. J Arthroplasty 2020; 35 (12) 3512-3516
    CrossrefPubMedGoogle Scholar
  • 16 Lee D, Lee R, Strum D, Heyer JH, Swansen T, Pandarinath R. The impact of chronic kidney disease on postoperative complications in patients undergoing revision total knee arthroplasty: a propensity matched analysis. J Clin Orthop Trauma 2020; 11 (01) 147-153
    CrossrefPubMedGoogle Scholar
  • 17 Ottesen TD, Zogg CK, Haynes MS, Malpani R, Bellamkonda KS, Grauer JN. Dialysis patients undergoing total knee arthroplasty have significantly increased odds of perioperative adverse events independent of demographic and comorbidity factors. J Arthroplasty 2018; 33 (09) 2827-2834
    CrossrefPubMedGoogle Scholar
  • 18 Krebs OK, Warren JA, Anis HK. et al. Estimated glomerular filtration rate as a risk stratification tool for early complications in revision total hip and knee arthroplasty. J Arthroplasty 2020; 35 (05) 1315-1322
    CrossrefPubMedGoogle Scholar
  • 19 Schwartz AM, Wilson JM, Farley KX, Bradbury Jr TL, Guild III GN. Concomitant malnutrition and frailty are uncommon, but significant risk factors for mortality and complication following primary total knee arthroplasty. J Arthroplasty 2020; 35 (10) 2878-2885
    CrossrefPubMedGoogle Scholar
  • 20 Nelson CL, Elkassabany NM, Kamath AF, Liu J. Low albumin levels, more than morbid obesity, are associated with complications after TKA. Clin Orthop Relat Res 2015; 473 (10) 3163-3172
    CrossrefPubMedGoogle Scholar
  • 21 Mooney L, Lewis PL, Campbell DG, Peng Y, Hatton A. Rates and outcomes of total knee replacement for rheumatoid arthritis compared to osteoarthritis. ANZ J Surg 2019; 89 (03) 184-190
    CrossrefPubMedGoogle Scholar
  • 22 Vakharia AM, Cohen-Levy WB, Vakharia RM, Sodhi N, Mont MA, Roche MW. Perioperative complications in patients with rheumatoid arthritis following primary total knee arthroplasty: an analysis of 102,898 patients. J Knee Surg 2019; 32 (11) 1075-1080
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Böhm P, Holy T, Pietsch-Breitfeld B, Meisner C. Mortality after total knee arthroplasty in patients with osteoarthrosis and rheumatoid arthritis. Arch Orthop Trauma Surg 2000; 120 (1-2): 75-78
    CrossrefPubMedGoogle Scholar
  • 24 Stundner O, Danninger T, Chiu YL. et al. Rheumatoid arthritis vs osteoarthritis in patients receiving total knee arthroplasty: perioperative outcomes. J Arthroplasty 2014; 29 (02) 308-313
    CrossrefPubMedGoogle Scholar
  • 25 Rudasill SE, Liu J, Kamath AF. Revisiting the international normalized ratio (INR) threshold for complications in primary total knee arthroplasty: an analysis of 21,239 cases. J Bone Joint Surg Am 2019; 101 (06) 514-522
    CrossrefPubMedGoogle Scholar
  • 26 Fang M, Noiseux N, Linson E, Cram P. The effect of advancing age on total joint replacement outcomes. Geriatr Orthop Surg Rehabil 2015; 6 (03) 173-179
    CrossrefPubMedGoogle Scholar
  • 27 Basques BA, Bell JA, Sershon RA, Della Valle CJ. The influence of patient gender on morbidity following total hip or total knee arthroplasty. J Arthroplasty 2018; 33 (02) 345-349
    CrossrefPubMedGoogle Scholar
  • 28 Robinson J, Shin JI, Dowdell JE, Moucha CS, Chen DD. Impact of gender on 30-day complications after primary total joint arthroplasty. J Arthroplasty 2017; 32 (08) 2370-2374
    CrossrefPubMedGoogle Scholar
  • 29 Tohidi M, Brogly SB, Lajkosz K, Grant HJ, VanDenKerkhof EG, Campbell AR. Ten-year mortality and revision after total knee arthroplasty in morbidly obese patients. J Arthroplasty 2018; 33 (08) 2518-2523
    CrossrefPubMedGoogle Scholar
  • 30 Mohamed NS, Wilkie WA, Remily EA. et al. The rise of obesity among total knee arthroplasty patients. J Knee Surg 2020; (May): DOI: 10.1055/s-0040-1710566.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Dowsey MM, Choong PFM, Paxton EW, Spelman T, Namba RS, Inacio MCS. Body mass index is associated with all-cause mortality after THA and TKA. Clin Orthop Relat Res 2018; 476 (06) 1139-1148
    CrossrefPubMedGoogle Scholar
  • 32 Roth A, Anis HK, Emara AK. et al; Cleveland Clinic OME Arthroplasty Group.. The potential effects of imposing a body mass index threshold on patient-reported outcomes after total knee arthroplasty. J Arthroplasty 2021; 36 (7S): S198-S208
    CrossrefPubMedGoogle Scholar
  • 33 Hinman AD, Chan PH, Prentice HA, Paxton EW, Okike KM, Navarro RA. The association of race/ethnicity and total knee arthroplasty outcomes in a universally insured population. J Arthroplasty 2020; 35 (06) 1474-1479
    CrossrefPubMedGoogle Scholar
  • 34 Zhang W, Lyman S, Boutin-Foster C. et al. Racial and ethnic disparities in utilization rate, hospital volume, and perioperative outcomes after total knee arthroplasty. J Bone Joint Surg Am 2016; 98 (15) 1243-1252
    CrossrefPubMedGoogle Scholar
  • 35 Blum MA, Singh JA, Lee GC, Richardson D, Chen W, Ibrahim SA. Patient race and surgical outcomes after total knee arthroplasty: an analysis of a large regional database. Arthritis Care Res (Hoboken) 2013; 65 (03) 414-420
    CrossrefPubMedGoogle Scholar
  • 36 Belmont Jr PJ, Goodman GP, Waterman BR, Bader JO, Schoenfeld AJ. 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 (01) 20-26
    CrossrefPubMedGoogle Scholar
  • 37 Clement ND, Jenkins PJ, Brenkel IJ, Walmsley P. Predictors of mortality after total knee replacement: a ten-year survivorship analysis. J Bone Joint Surg Br 2012; 94 (02) 200-204
    CrossrefPubMedGoogle Scholar
  • 38 Hooper GJ, Rothwell AG, Hooper NM, Frampton C. The relationship between the American Society of Anesthesiologists physical rating and outcome following total hip and knee arthroplasty: an analysis of the New Zealand Joint Registry. J Bone Joint Surg Am 2012; 94 (12) 1065-1070
    CrossrefPubMedGoogle Scholar
  • 39 Lizaur-Utrilla A, Gonzalez-Parreño S, Miralles-Muñoz FA, Lopez-Prats FA. Ten-year mortality risk predictors after primary total knee arthroplasty for osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2015; 23 (06) 1848-1855
    CrossrefPubMedGoogle Scholar
  • 40 Glassou EN, Pedersen AB, Hansen TB. Is decreasing mortality in total hip and knee arthroplasty patients dependent on patients' comorbidity?. Acta Orthop 2017; 88 (03) 288-293
    CrossrefPubMedGoogle Scholar