The Journal of Arthroplasty Vol. 23 No. 6 Suppl. 1 2008

In Hospital Complications AfterTotal 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 studyprospectively collected data on systemic and local in hospital complications after15383 joint arthroplasties, which included 8230 total hip arthroplasties and 7153total knee arthroplasties. In general, the incidence of complications was higher afterknee arthroplasty, simultaneous bilateral surgery, and revision surgery. There were22 (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 periprostheticfractures, and 18 dislocations. Total joint arthroplasty, despite its success, can beassociated with rare serious and life-threatening complications. This study provides abaseline 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 thatimproves the quality of life and function of patientsaffected by arthritis of the hip and knee. Althoughconsidered a safe elective surgery, rare complications canjeopardize the outcome of arthroplasty and, at worst, leadto demise of patients [1-4].

The recent improvements in the surgical techniqueshave contributed to a marked reduction in mortality after

From the Rothman Institute of Orthopaedics at Thomas JeffersonUniversity, Philadelphia, Pennsylvania.

Submitted November 21, 2007; accepted May 11, 2008.Each author certifies that their institution has approved the

human protocol for this investigation and that all investigationswere conducted in conformity with ethical principles of research.

Benefits or funds were received in partial or total support of theresearch material described in this article. These benefits or supportwere received from the following sources: JP, PFS, WJH, and RHRreceived funding from Stryker Orthopaedics (Mahwah, NJ, USA).

Reprint requests: Javad Parvizi, MD, Rothman Institute ofOrthopedics at Thomas Jefferson Hospital, 925 Chestnut Street,Philadelphia, PA 19107.

© 2008 Published by Elsevier Inc.0883-5403/08/2306-0025$34.00/0doi:10.1016/j.arth.2008.05.011

139

elective joint arthroplasty [3,4]. However, because of theadvances in preventive medicine and the marvel ofmodern medical care, resulting in better survivorship ofpatients, joint arthroplasty is being performed in olderand sicker patients [5-7]. Furthermore, because preva-lence of osteoarthritis increases with age [8], the higherlife expectancy and the upcoming massive cohort fromthe “old baby boomers” will lead to higher number ofjoint arthroplasties being performed. The progressiveincrease in the number of arthroplasties per year hasalready been witnessed in the United States during the1990s and the first years of this decade [9]. By the year2030, the projected demand for primary total hip andknee arthroplasties (THA and TKA, respectively) in theUnited States is estimated to increase by 174% to 572000and by 673% to 3.48 million, respectively [10]. It is,hence, plausible that a higher incidence of medicalcomplications in this growing joint arthroplasty popula-tion will be observed.

The latter, if true, would imply that better preoperativemedical optimization and strict postoperative surveillanceof these patients are required. This study was designed toelucidate the incidence, timing, and severity of the earlycomplications that occur in the hospital setting after TJA.

140 The Journal of Arthroplasty Vol. 23 No. 6 Suppl 1 September 2008

Materials and Methods

A prospective database collected daily information onevery patient undergoing elective joint arthroplasty at ourinstitution. This study did not include patients receivingpartial joint arthroplasties or nonarthroplasty procedures.The period of study was from January 2000 to August2006; during this time, 15383 hip and knee arthroplastieswere performed in 13517 patients, 5728 of whom weremen who had a mean age of 61 years (range, 15-93 years)and 7789 were women who had a mean age of 65 years(range, 13-97 years) (Table 1).

All patients in this cohort undergoing elective arthro-plasty received preoperative medical evaluation andclearance for surgery. The hospital course of the patientswas followed very closely, and any complicationsidentified by the caring internist or orthopedic residentwere recorded. A full-time research fellow was dedicatedto this study. During this study, there were 2 differentapproaches to capture the complications that presentduring the patient's hospitalization. Most of the compli-cations identified were captured from the resident'sworksheets from the joint arthroplasty service andentered into the database. The electronic medical recordof the patients, in particular, the discharge summary, wasalso searched to capture any complications that may havegone undetected using the first method.

Hypotensive regional anesthesia was used for allpatients unless contraindicated or unsuccessful to achieve.Joint arthroplasty was carried out in a laminar flow roomwith all members of the surgical team wearing bodyexhaust suits during surgery. All operations were per-formed by or under close supervision of one arthroplastysurgeon. (RHR, WJH, PFS, JJP, and JP performed 95% ofthe operations included during the study period.)

Most hip arthroplasties were performed in supineposition through an anterolateral approach. (Fewer than5% of hip arthroplasties were performed through a directanterior approach.) Total knee arthroplasties were per-formed under tourniquet using medial parapatellararthrotomy approach. Cementless prostheses were usedfor the hip arthroplasty cases, and cemented fixation wasused for total knee cases.

Multiple standardized protocols were implemented forall patients. The prophylactic anticoagulation regimen wasthe same throughout the study period. This consisted ofadministration of warfarin on the day of surgery and

Table 1. Demographic Distribution

Joint Procedure Patients (no.) Bilateral (no.)

Hip Revision 1427 8Primary arthroplasty 6272 523Total arthroplasty 7699 531

Knee Revision 645 8Primary arthroplasty 5173 1327Total arthroplasty 5818 1335

Total TJA 13 517 1866

continued for 6 weeks aiming for an internationalnormalized ratio of 1.5 to 2.0. All knee patients alsoreceived 1000 U of intravenous heparin before inflation oftourniquet during knee arthroplasties. Intravenous anti-biotics, namely, first-generation cephalosporin, or vanco-mycin for those with allergy, were administeredpreoperatively and for 24 hours after the surgery. Allpatients were mobilized early in the postoperative period,either the day of surgery or the next morning.

All patients in this cohort were followed closely by aninternist. Patient monitoring of respiratory rate, heartrate, blood pressure, and pulse oximetry were carried outat frequent intervals (every 6 hours) by the nursing staff.Daily laboratory tests including complete blood count,renal function test, blood chemistry, prothrombin time,and international normalized ratio were also performed.Any abnormal changes in these parameters that weredeemed to be clinically significant were further investi-gated. Additional tests such as the liver function test,troponins, chest radiographs, electrocardiogram, Dopplersonogram, or computerized tomography were ordered asnecessary by the caring physician.

Definition of Complications

Complications included in this study occurred in thehospital before discharge. The complications were cate-gorized into systemic (medical) and local (orthopedic)according to the nature of the event. Furthermore, thecomplications were subcategorized into major and minor,depending on their severity. Complications were con-sidered major if they required complex surgical ormedical intervention or if they were deemed to pose athreat to patient's life or result in functional impairment.Minor complications were those that necessitated addi-tional observation or required medical treatment. Post-operative anemia was not included as a complication inthis study.

Myocardial infarction was determined based on the risein the troponins levels and/or electrocardiogram changes.Acute renal failure was defined as an abrupt decline inrenal function parameters with reduced urine output.Pulmonary embolus was diagnosed based on radiologictests, namely, the presence of emboli in the pulmonaryvasculature using multidetector computerized tomogra-phy, and for the patients with chronic renal failure orallergies to contrast agents, the diagnosis was based on a

of the Patients Undergoing TJA

Unilateral (no.) Total (no.) Age (mean) BMI (mean)

1419 1435 65 285749 6795 62 297168 8230 62 28637 653 64 32

3846 6500 65 324483 7153 65 32

11651 15383 63 30

Table 2. Incidence of In Hospital Systemic Complications After TJA

Procedure

TJA

Hip arthroplasty Knee arthroplasty

Revision Primary Revision Primary

No. % No. % No. % No. % No. %

No. of procedures 13517 1427 6272 645 5173Major 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%

In Hospital Complications After Total Joint Arthroplasty � Pulido et al 141

high probability ventilation perfusion scan. Deep venousthrombosis was diagnosed using Doppler ultrasound.Persistent wound drainage was defined as any clinicallysignificant amount of drainage from the wound morethan 48 hours after the index surgery, which requiredfurther treatment.

Statistical Analysis

Descriptive statistics and Fisher exact test were usedfor analysis of categorical data. Continuous data wereanalyzed using descriptive statistics and nonpaired t test.Univariate regression analysis was performed on risk

142 The Journal of Arthroplasty Vol. 23 No. 6 Suppl 1 September 2008

factors for complications. All analyses were performedusing SPSS version 13 (SPSS, Chicago, Ill).

Results

Incidence of Systemic Complications

There were a total of 955 (7.1%) systemic complica-tions after TJA. Of these, 486 (3.6%) were classified asmajor, and the remaining 469 (3.47%) were consideredminor (Table 2). Major systemic complications werefurther categorized into different systems, which includedcardiovascular, pulmonary, neurologic, gastrointestinal,blood, and other. Primary and revision knee arthroplastyaccounted for most systemic complications (62%, 302/486). Most of the life-threatening complications (74%)were cardiovascular in origin, with symptomatic pulmon-ary embolism being the most prevalent complication afterTJA in this category (1.12% overall incidence).

Four hundred sixty-nine minor systemic complicationswere detected in this cohort. They affected 5 differentsystems: cardiovascular, pulmonary, neurologic, gastro-intestinal, and urinary (Table 2).

Incidence of Local Complications

Local complications occurred after 473 arthroplasties(3.5%), of which 109 (0.81%) were deemed to be majorcomplications (Table 3).

Vascular injuries represented the most feared majorlocal complication. Eleven vascular injuries occurred afterTKA. Popliteal artery thrombosis was the most commoncause after knee surgery (82%, 9/11). The other 2 patientspresented with a popliteal artery laceration and eventualthrombosis. Five vascular complications were identifiedafter hip surgery. Direct arterial laceration was the mostcommon mechanism of injury during THA (4/5). Threefemoral artery lacerations and one external iliac vessels

Table 3. Incidence of In Hospital L

Procedure

TJA

Hip

Revision

No. % No. %

No. of procedures 13517 1427Major local complications 109 0.80% 27 1.89%Dislocation 18 0.13% 13 0.91%Periprosthetic fracture 25 0.18% 8 0.56%Deep periprosthetic infection 11 0.08% 3 0.21%Arthrotomy dehiscence 3 0.01% 0 0.00%Peripheral nerve injury 29 0.21% 1 0.07%Vascular injury 16 0.12% 2 0.14%Compartment syndrome 7 0.05% 0 0.00%Minor local complications 364 2.69% 62 4.34%Drainage 274 2.03% 35 2.45%Wound infection 36 0.27% 15 1.05%Hematoma 24 0.18% 9 0.63%Blisters 16 0.12% 0 0.00%Cellulitis 12 0.09% 3 0.21%Decubitus ulcers 2 0.01% 0 0.00%

laceration were diagnosed. The other patient had afemoral artery thrombosis. Four-compartment fasciotomywas performed in 8 of the 16 patients for compartmentsyndrome, 5 after TKA and 3 after THA.

Major complications required further surgical interven-tion, with the exception of peripheral nerve injuries inwhich a conservative management was elected. Nearly allminor complications were related to the surgical incision,the most common of which was wound drainage (2.03%,274/13517) (Table 3).

Timing of Complications

The timingof complications varied according to the typeofsurgery. Most of the complications occurred within 4 days ofthe index surgery. Complications after primary arthroplastypresented earlier compared with those developing afterrevision arthroplasty. The average length of hospital staywas3.8 days (range, 1-106 days). Patients undergoing revisionarthroplasty had a longer hospital stay (mean = 5 days forknees and 4 days for hips) than the primary arthroplastycounterparts (mean = 4 and 3 days, respectively).

Risk Factors for Major Complications

Certain factors were analyzed with respect to theirpotential influence on the incidence of major systemic andlocal complications. Univariate analysis identified older age(P b .0001), shorter stature (P b .02), revision arthroplasty(P b .0001), knee arthroplasty surgery (P b .0001), andsimultaneous bilateral procedure (P b .001) to be significantpredictor of major systemic complications (Table 4). Revi-sion arthroplasty was an important predictor of major localcomplications (P b .0001) (Table 4).

Mortality

There were 22 in hospital deaths in this cohort of 13517patients (Table 5), an incidence of 0.16%. Most of deaths

ocal Complications After TJA

arthroplasty Knee arthroplasty

Primary Revision Primary

No. % No. % No. %

6272 645 517330 0.48% 9 1.26% 43 0.83%4 0.06% 0 0.00% 1 0.02%8 0.13% 5 0.78% 4 0.08%2 0.03% 3 0.47% 3 0.06%0 0.00% 0 0.00% 3 0.06%

12 0.19% 0 0.00% 16 0.31%3 0.05% 1 0.02% 10 0.19%1 0.02% 0 0.00% 6 0.12%

159 2.54% 42 6.51% 101 1.95%132 2.10% 33 5.12% 74 1.43%10 0.16% 5 0.78% 6 0.12%10 0.16% 1 0.16% 4 0.08%3 0.05% 3 0.47% 10 0.19%4 0.06% 0 0.00% 5 0.10%0 0.00% 0 0.00% 2 0.04%

Table 4. Risk Factors for Major Complications After TJA

Variable

Without complications Major systemic complications

P

Major local complications

PNo. No. No.

Female 6954 260 (53.5%) .123 73 (66%) .09Male 5114 226 (46.5%) 36 (34%)Age (y) 64 (13-97) 71 (31-92) .0001 66 (30-91) .464Height (cm) 169.6 (100.1-234.0) 168.3 (125.3-234.0) .022 168.4 (142.0-190.5) .08Weight (kg) 85.9 (31.0-240.0) 87.0 (37.6-172.4) .375 83.3 (45.6-163.3) .961BMI 29.9 (13.2-69.9) 30.7 (11.9-66.1) .135 29.2 (15.5-48.8) .078ArthroplastyPrimary 12770 384 (79%) .0001 77 (71%) .0001Revision 1947 102 (21%) 32 (29%)Hip 7367 199 (41%) .0001 54 (50.5%) .115Knee 6740 287 (59%) 55 (49.5%)Bilateral 1761 95 (19.5%) .001 13 (12.1%) .778Unilateral 11168 391 (80.5%) 96 (87.9%)

In Hospital Complications After Total Joint Arthroplasty � Pulido et al 143

(80%) occurred within the first 6 days after surgery. Theincidence of in hospital mortality at 0.5% was higher inthe revision arthroplasty group compared with 0.1% inthe primary arthroplasty cohort (P b .05). Cardiovascularcomplications (such as acute coronary syndrome, pul-monary embolism, fatal arrhythmias, and cardiopulmon-ary arrest) were the most common cause of death.

Discussion

Total joint arthroplasty represents one of the greatestadvances in modern orthopedic surgery and continues tobe one of the safest and the most effective surgicalprocedures, providing immense relief of pain andimprovement in function for a large number of patients[2]. Because of the shift toward an elderly society, with a

Table 5. Intrahospital Mortality A

No. Sex Age (y) Procedure Joint Side Postoperat

1 F 83 Revision Hip Unilateral 02 M 81 Revision Hip Unilateral 03 M 87 Revision Hip Unilateral 14 M 65 Revision Hip Unilateral 15 M 81 Revision Knee Unilateral 16 F 73 Primary Knee Unilateral 17 F 53 Primary Knee Unilateral 18 M 79 Primary Knee Unilateral 29 F 66 Primary Knee Bilateral 210 F 80 Primary Hip Unilateral 211 F 48 Revision Hip Unilateral 212 M 73 Revision Hip Bilateral 213 F 64 Revision Knee Unilateral 214 F 75 Primary Hip Unilateral 215 M 57 Primary Knee Unilateral 416 F 89 Primary Hip Unilateral 517 M 79 Primary Hip Unilateral 618 M 81 Primary Hip Unilateral 619 M 74 Primary Hip Unilateral 1220 F 72 Primary Knee Unilateral 2321 M 79 Revision Knee Unilateral 3422 F 94 Primary Hip Unilateral 72

F indicates female; M, male.

higher prevalence of osteoarthritis, an increasing numberof primary and revision arthroplasties will be performed inthe coming years [9]. The recent advances in the design ofprosthesis, delivery of surgical care, and anesthesiatechniques have further contributed to the success ofmodern-day joint arthroplasty [3,4]. Furthermore, sub-stantial and parallel advances in themedical fields over therecent years have enabled a large number of patients withsevere illnesses to enjoy longer life expectancy and seekorthopedic care for their degenerative joints. Hence, TJA iscurrently being offered to some patients with seriouscomorbidities [5,6,11], who may have been deemedinappropriate candidates during the early years of jointarthroplasty. Despite the availability of this surgicalprocedure to the sick and frail patients, the mortalityand morbidity after TJA remains very low [4,12]. Deathsand complications after joint arthroplasty, however, can

fter Total Joint Arthroplasty

ive days Cause of death

Acute coronary syndromeCardiopulmonary arrest

Anoxic brain injury, respiratory failurePulmonary embolism

Pulmonary embolism, aspiration pneumonitisHypotension

PneumothoraxVascular injury

Acute coronary syndromeAsystole

Ventricular tachyarrhythmiaCardiopulmonary arrest

Gastrointestinal bleed, sepsisCardiopulmonary arrest

Respiratory failureAspiration pneumonia, sepsis

Aspiration pneumonia, arrhythmiaAcute coronary syndrome, asystole

SepsisAnoxic brain injury, aspiration, pulmonary embolism

Massive retroperitoneal hemorrhagePulmonary embolism, sepsis, respiratory failure

144 The Journal of Arthroplasty Vol. 23 No. 6 Suppl 1 September 2008

and do occur [4,13]. This study, designed with theintention of identifying complications presented in thehospital after joint arthroplasty, highlights some impor-tant findings. First, the study demonstrated that aconsiderable number of medical complications occur inup to 4.4% of the joint arthroplasty patients. All thesecomplications were deemed to be life threatening becauselack of emergent intervention could have resulted incatastrophic consequences. Even if one assumes thatemergent medical care could have been provided formost of these patients if they were outside the hospital,one cannot overlook the relatively high incidence ofcardiac serious events that occurred in this patientpopulation. Furthermore, all of the latter occurred despiteintensive and rigorous medical evaluation of all thepatients in this elective joint arthroplasty cohort. Finally,this study demonstrated that most of the complicationsoccur within the expected typical 4-day hospital stay of astandard joint arthroplasty. The incidence of in-hospitalmortality and major complications such as myocardialinfarction in this cohort is similar to other reports [12,14].Furthermore, patients that developed major medicalcomplications were older (mean = 71 years) comparedwith those patients without any complication (mean = 64years). Advanced age identified in our study as asignificant risk factor also agrees with the findings ofprevious studies [14,15]. Another important finding ofthis study is that major systemic complications morefrequently presented after bilateral joint arthroplasty. Thisfinding is in agreement with previous publications citing ahigher postoperative complications after bilateral simulta-neous arthroplasty [16-18]. Although the number of life-threatening complications appears higher in females andin obese patients, neither sex nor body mass index (BMI)reached statistical significance. Revision arthroplasty wasassociated with a longer hospital stay and higher rates ofmajor complications and mortality. These findings weresimilar to data demonstrated by Mohamed et al [19] in arecent population-based study.

There are some caveats to this study. First, this studywas performed using prospectively collected data from asingle, high volume, and specialized joint center wherestandardized protocols are in place and patients receivethorough preoperative medical evaluation and are fol-lowed diligently by internists postoperatively. It is, hence,plausible that the incidence of complications would behigher in centers if the aforementioned protocols werenot instituted. Conversely, the implementation of theseprotocols with closer postoperative surveillance, includingthe use of pulse oximetry, and the availability of modernimaging modalities such as multidetector CT scan mayhave resulted in “overdetection” of complications such aspulmonary embolism that may have otherwise goneunnoticed [20]. Second, extensive effort was made toensure that every complication occurring in the hospitalwas captured. Despite the prospective nature of thisstudy, it is possible, though unlikely, that some complica-tions may have escaped. The latter, if true, would implythat the actual incidence of complications is higher thanwhat is reported.

We believe that this prospective study from a singleinstitution in a relatively large number of patients mayserve to provide a baseline of complications that may beexpected after elective joint arthroplasty.

References

1. Coventry MB, Beckenbaugh RD, Nolan DR, et al.2,012 total hip arthroplasties. A study of postoperativecourse and early complications. J Bone Joint Surg Am1974;56:273.

2. Kavanagh BF, Dewitz MA, Ilstrup DM, et al. Charnleytotal hip arthroplasty with cement. Fifteen-yearresults. J Bone Joint Surg Am 1989;71:1496.

3. Parvizi J, Holiday AD, Ereth MH, et al. The FrankStinchfield Award. Sudden death during primary hiparthroplasty. Clin Orthop Relat Res 1999:39.

4. Parvizi J, Johnson BG, Rowland C, et al. Thirty-daymortality after elective total hip arthroplasty. J BoneJoint Surg Am 2001;83-A:1524.

5. Kreder HJ, Berry GK, McMurtry IA, et al. Arthro-plasty in the octogenarian: quantifying the risks.J Arthroplasty 2005;20:289.

6. Pagnano MW, McLamb LA, Trousdale RT. Primaryand revision total hip arthroplasty for patients 90years of age and older. Mayo Clin Proc 2003;78:285.

7. Boettcher WG. Total hip arthroplasties in the elderly.Morbidity, mortality, and cost effectiveness. ClinOrthop Relat Res 1992:30.

8. Lawrence RC, Helmick CG, Arnett FC, et al. Estimatesof the prevalence of arthritis and selected musculos-keletal disorders in the United States. Arthritis Rheum1998;41:778.

9. Kurtz S, Mowat F, Ong K, et al. Prevalence of primaryand revision total hip and knee arthroplasty in theUnited States from 1990 through 2002. J Bone JointSurg Am 2005;87:1487.

10. Kurtz S, Ong K, Lau E, et al. Projections of primary andrevision hip and knee arthroplasty in the United Statesfrom 2005 to 2030. J Bone Joint Surg Am2007;89:780.

11. Begg CB, Cramer LD, Hoskins WJ, et al. Impact ofhospital volume on operative mortality for majorcancer surgery. JAMA 1998;280:1747.

12. Mantilla CB, Horlocker TT, Schroeder DR, et al.Frequency of myocardial infarction, pulmonaryembolism, deep venous thrombosis, and death fol-lowing primary hip or knee arthroplasty. Anesthe-siology 2002;96:1140.

13. Lie SA, Engesaeter LB, Havelin LI, et al. Earlypostoperative mortality after 67,548 total hip replace-ments: causes of death and thromboprophylaxis in 68hospitals in Norway from 1987 to 1999. Acta OrthopScand 2002;73:392.

14. Gill GS, Mills D, Joshi AB.Mortality following primarytotal knee arthroplasty. J Bone Joint Surg Am 2003;85-A:432.

15. Soohoo NF, Lieberman JR, Ko CY, et al. Factorspredicting complication rates following total kneereplacement. J Bone Joint Surg Am 2006;88:480.

In Hospital Complications After Total Joint Arthroplasty � Pulido et al 145

16. Bullock DP, Sporer SM, Shirreffs Jr TG. Compar-ison of simultaneous bilateral with unilateral totalknee arthroplasty in terms of perioperative compli-cations. J Bone Joint Surg Am 2003;85-A:1981.

17. Restrepo C, Parvizi J, Dietrich T, et al. Safety ofsimultaneous bilateral total knee arthroplasty. Ameta-analysis. J Bone Joint Surg Am 2007;89:1220.

18. Morrey BF, Adams RA, Ilstrup DM, et al. Complica-tions and mortality associated with bilateral or

unilateral total knee arthroplasty. J Bone Joint SurgAm 1987;69:484.

19. Mahomed NN, Barrett JA, Katz JN, et al. Rates andoutcomes of primary and revision total hip replace-ment in the United States Medicare population.J Bone Joint Surg Am 2003;85-A:27.

20. Parvizi J, Smith EB, Pulido L, et al. The rise in theincidence of pulmonary embolus after joint arthro-plasty: is modern imaging to blame. Clin OrthopRelat Res 2007;463:107.