Margaret Wood, M.D.

, Editor
Anesthesiology 2002; 96:11406 2002 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
Frequency of Myocardial Infarction, Pulmonary Embolism,
Deep Venous Thrombosis, and Death following Primary
Hip or Knee Arthroplasty
Carlos B. Mantilla, M.D.,* Terese T. Horlocker, M.D., Darrell R. Schroeder, M.S., Daniel J. Berry, M.D.,
David L. Brown, M.D.
Background: There is limited information about the fre-
quency of perioperative complications after elective primary
orthopedic total hip and knee arthroplasty in contemporary
practice. The purpose of this study was to determine the fre-
quency of clinically relevant myocardial infarction, pulmonary
embolism, deep venous thrombosis, and death within 30 days
after elective primary hip or knee arthroplasty treated accord-
ing to contemporary perioperative management.
Methods: The authors examined the medical records of con-
secutive patients undergoing hip or knee arthroplasty at their
institution in a 10-yr period. Prospectively collected databases
were used to identify patients with the diagnosis of myocardial
infarction, pulmonary embolism, deep venous thrombosis, or
death using strict validation criteria and diagnostic-certainty
categories.
Results: A total of 10,244 patients underwent primary total
hip or knee arthroplasty in the period of study. Of these, 224
patients had one or more adverse events (overall event rate:
2.2%; myocardial infarction: 0.4%; pulmonary embolism: 0.7%;
deep venous thrombosis: 1.5%; death: 0.5%). Most adverse
events (myocardial infarction, pulmonary embolism, and
death) increased in frequency with older age, particularly for
patients aged 70 yr or older. Myocardial infarction occurred
more frequently in male patients. There were no differences in
the overall event frequency between types of procedure. How-
ever, pulmonary embolism was highest in patients undergoing
bilateral knee operations.
Conclusions: The overall frequency of serious complications
within 30 days after primary total hip or knee arthroplasty with
contemporary practice was 2.2%. Accurate knowledge of the
perioperative risks associated with widely performed elective
operations can be used to implement management strategies
that may further improve patient outcomes and decrease cost.
INCREASING numbers of operative procedures are
being performed in older patients.
13
Because the
prevalence of hip and knee osteoarthritis increases
with age, major orthopedic surgery is now common-
place in ever-older individualsa population in which
some degree of cardiac, pulmonary, cerebral, renal,
and hepatic disease is often present.
1
Importantly,
these procedures are commonly performed in low-
volume surgical settings. For example, in the United
Kingdom, although nearly 35,000 total knee replace-
ments are implanted annually, only 9% of orthopedic
surgeons perform more than 90 per year.
4
Although
somewhat controversial, there are no denitive data to
support the assumption that improved perioperative
outcomes are achieved in hospitals with larger surgi-
cal volumes.
5,6
Therefore, a thorough understanding
of the potential complications in this operative group
is paramount to the delivery of the highest-quality
medical care.
Previous studies
3,715
have examined the frequency of
myocardial infarction, deep venous thrombosis, pulmo-
nary embolism, or death after lower extremity arthro-
plasty. Most of these studies were performed in small
patient populations in selected hospitals or predate
current perioperative care of the arthroplasty pa-
tient.
1,2,1625
Recent studies, including large numbers of
patients and using current medical treatments for pa-
tients undergoing major orthopedic operations, are still
lacking.
The goal of this study was to determine the frequency
of clinically signicant complications in the periopera-
tive period for patients undergoing primary total hip or
knee joint replacement at a single institution with a
large, broadly based patient population. Accurate knowl-
edge of the actual contemporary risks of perioperative
complications is valuable to the individuals decision-
making process when considering an elective operation.
The identication of factors that predispose patients to
perioperative complications offers the potential to opti-
mize the outcome of operative procedures and to focus
on strategies that may favorably impact the cost of med-
ical care.
12,14,2630
This article is featured in This Month in Anesthesiology.
Please see this issue of ANESTHESIOLOGY, page 5A.

* Assistant Professor, Associate Professor, Department of Anesthesiology,

Statistician, Department of Health Sciences Research, Associate Professor,
Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota. Pro-
fessor and Chairman, Department of Anesthesia, The University of Iowa, Iowa
City, Iowa.
Received from the Departments of Anesthesiology, Health Sciences Research,
and Orthopedic Surgery, Mayo Clinic and Foundation, Rochester, Minnesota.
Submitted for publication July 31, 2001. Accepted for publication January 11,
2002. Supported by the Mayo Foundation, Rochester, Minnesota.
Address reprint requests to Dr. Mantilla: Department of Anesthesiology, Mayo
Clinic, 200 First Street Southwest, Rochester Minnesota 55905. Address elec-
tronic mail to: mantilla.carlos@mayo.edu. Individual article reprints may be
purchased through the Journal Web site, www.anesthesiology.org.
Anesthesiology, V 96, No 5, May 2002 1140
Patients and Methods
Patients
After institutional review board approval (Mayo Clinic,
Rochester, Minnesota), two prospectively collected da-
tabases were used to identify all patients at our institu-
tion who underwent elective primary total hip or knee
arthroplasty between January 1, 1986 to December 31,
1995 and who experienced an adverse cardiac or pul-
monary complication in the perioperative period. In
accordance with Minnesota state law, patients who had
denied access to their medical records were excluded
from the study.
The Total Joint Registry is a prospectively collected,
computerized database of all joint replacements per-
formed at the Mayo Clinic since 1969 and has been
described previously.
31
Detailed information about op-
erative approach and prosthesis data are abstracted and
entered in a computerized database by joint registry
personnel. Data about operative indication, preoperative
diagnoses, and postoperative medical and surgical com-
plications are collected in standardized data collection
forms at hospital discharge. Patients are routinely seen at
2 or 3 months after their procedure. The Total Joint
Registry is highly integrated with other institutional sys-
tems (e.g., registration, billing, appointment scheduling),
which provide up-to-date contact information and facil-
itate patient follow-up. A standardized form and formal
chart review are performed at 1, 2, and 5 yr and every
5 yr thereafter. The overall rate of clinical follow-up in
the Total Joint Registry exceeds 95%.
31
The Total Joint
Registry was screened to identify all patients who re-
ceived one or more elective primary total hip or knee
replacements in the study period. Patients treated with
nonelective hip arthroplasty for hip fracture were ex-
cluded. For patients who underwent more than one
operative procedure during the study period, only the
rst procedure was considered; thus, only one operative
episode was examined for each patient. Using the Total
Joint Registry, all patients known to have experienced
arteriovascular or thromboembolic complications or
death within the rst year after the date of operation
were identied. The medical records of those patients
were retrospectively reviewed.
The institutional unied medical record system con-
tains information about all patients who have ever been
examined at our institution.
32
The Medical Index is a set
of databases that serve as an index to the patients
medical record. This index also was used to identify all
study patients who had a diagnosis of coronary artery
disease, myocardial ischemia, myocardial infarction, pul-
monary embolism, deep venous thrombosis, or death at
any time during the previous year, the year of the surgi-
cal event, or the year after the surgical event. The med-
ical records of these patients also were retrospectively
reviewed.
This broad initial screening methodology, which iden-
tied all patients experiencing potential adverse events
occurring within 1 yr after the operation, was used to
maximize case ascertainment. Strict validation criteria
were subsequently used for the denition of an adverse
perioperative event (myocardial infarction, pulmonary
embolism, deep venous thrombosis, or death). Each
episode of myocardial infarction, pulmonary embolism,
or deep venous thrombosis occurring during the initial
30 days after the date of operation was categorized into
the highest level of diagnostic certaintydenite, prob-
able, or no eventaccording to previously dened
criteria.
27,3335
Denite perioperative myocardial infarction was de-
ned as any episode occurring within 30 days after the
date of operation in which either routine or clinically
relevant cardiac evaluation (new onset of symptoms con-
sistent with cardiac morbidity) demonstrated any two of
the following three criteria: (1) creatine kinase MB frac-
tion greater than 3 times the upper limit of normal (or a
creatine kinase 3 times normal if no creatine kinase
MB fraction was obtained; (2) electrocardiographic evi-
dence of new Q waves greater or equal to 0.04 s; or
(3) new wall motion abnormality (by echocardiography
or scintillation scanning). Probable perioperative myo-
cardial infarction included episodes occurring within
30 days after the date of operation in which (1) one of
the three criteria above was met and (2) the medical
record indicated that a physician had made the diagnosis
of myocardial infarction. Perioperative pulmonary em-
bolism was categorized as denite when it occurred
within 30 days after the date of operation and either (1)
pulmonary angiography, computed tomographic scan,
magnetic resonance imaging, echocardiographic visual-
ization, or pathologic examination of thrombus removed
at surgery or autopsy conrmed pulmonary embolism;
or (2) the onset of new symptoms highly suggestive of
acute pulmonary embolism were associated with a per-
fusion or ventilationperfusion lung scan interpreted as
high probability for pulmonary embolism. Perioperative
pulmonary embolism was categorized as probable if
conrmatory tests were either not performed or were
indeterminate and (1) the medical record indicated that
a physician made a diagnosis of pulmonary embolism;
(2) signs and symptoms consistent with pulmonary em-
bolism were present; and (3) the patient received a
course of anticoagulation therapy with heparin, warfa-
rin, or a similar agent, or placement of an inferior vena
cava lter. Interim anticoagulation therapy while await-
ing diagnostic evaluation for suspected deep vein throm-
bosis or pulmonary embolism was not included as evi-
dence of an event. Perioperative deep venous
thrombosis was categorized as denite when (1) it oc-
curred within 30 days after the date of operation when
conrmed by venography, computed tomographic scan,
magnetic resonance imaging, or pathologic examination
1141 FREQUENCY OF ADVERSE EVENTS IN HIP OR KNEE SURGERY
Anesthesiology, V 96, No 5, May 2002
of thrombus removed at surgery or autopsy; or (2) the
onset of local or systemic symptoms suggestive of deep
venous thrombosis was associated with a documented
positive noninvasive diagnostic test: impedance plethys-
mography, continuous wave Doppler ultrasound, com-
pression duplex ultrasonography, radionuclide venogra-
phy, or radiolabeled brinogen leg scan. Perioperative
deep venous thrombosis was categorized as probable if
testing for the denite level of diagnostic certainty was
either not performed or was indeterminate and (1) the
medical record indicated that a physician made a diag-
nosis of deep vein thrombosis; (2) signs and symptoms
consistent with deep vein thrombosis were present; and
(3) the patient received a therapeutic course of antico-
agulation with heparin, warfarin, or a similar agent or a
surgical procedure for deep vein thrombosis. The end-
point of death was obtained from documented events in
the institutional databases and the social security index.
In patients with more than one adverse event (myo-
cardial infarction, pulmonary embolism, deep venous
thrombosis, or death), each episode was categorized
into the highest level of diagnostic certainty present for
each manifestation. Patients experiencing a periopera-
tive pulmonary embolism were considered to have an
associated probable deep venous thrombosis when no
lower extremity diagnostic testing was performed. All
patient records were abstracted by using a standardized
data collection form. Demographic data, surgical infor-
mation and date, and timing of adverse event and de-
tailed diagnostic criteria were recorded.
Statistical Analysis
The diagnostic certainty categories of denite and
probable were combined for analysis to maximize the
clinical relevance of these events. A preliminary analysis
was performed to conrm that the ages and sexes of the
denite and probable event groups did not differ signif-
icantly. The frequencies of myocardial infarction, pulmo-
nary embolism, deep venous thrombosis, and death
were calculated overall and also separately for patients
undergoing unilateral knee, bilateral knee, and total hip
arthroplasty. Age- and sex-specic frequencies were also
calculated. For each event type, multiple logistic regres-
sion analyses were performed to determine whether the
frequency of the event differed signicantly across cal-
endar time, age, sex, or type of procedure. For these
analyses, calendar time and age were treated as contin-
uous variables, whereas sex and type of procedure were
treated as categorical variables. In all cases, two-tailed P
values less than or equal to 0.05 were considered statis-
tically signicant.
Results
A total of 10,244 patients (4,775 male, 5,469 female)
who underwent elective primary total hip or knee joint
replacement surgery in the 10-yr period of study are
included in this article (table 1). There were an addi-
tional 158 patients who underwent one of these proce-
dures during the study period who were excluded from
the study because they had denied access to their med-
ical records. Most patients (80.6%) were 60 yr of age or
older at the time of surgery. The total number of patients
undergoing primary hip or knee arthroplasty, for diag-
noses other than fracture, remained relatively consistent
during the 10-yr interval from 1986 through 1995. No
differences in sex or age distributions were found over
the study period. Overall, 5,233 patients underwent pri-
mary hip replacement, 3,601 underwent unilateral knee
replacement, and 1,410 underwent bilateral knee re-
placement surgery (table 1). Nearly all ( 95%) of the
surgeries included in this study were performed by a
group of 20 orthopedic surgeons, with each surgeon per-
forming a median of 453 surgeries (range, 1321,273).
After the initial database screen, 423 patients were
identied as potentially having one or more adverse
events (myocardial infarction, pulmonary embolism,
deep venous thrombosis, or death) within 1 yr after the
hip or knee replacement surgery. The medical records of
these 423 patients were reviewed, and perioperative
adverse events were assigned diagnostic certainty cate-
gories as described in the Methods section. Two hun-
dred twenty-four patients were found to have experi-
enced one or more denite or probable adverse events
Table 1. Patient Characteristics According to Type of Procedure
Characteristic
Unilateral Knee
(N 3,601)
Bilateral Knee
(N 1,410)
Hip
(N 5,233)
Total
(N 10,244)
n % n % n % n %
Sex
Male 1,573 43.7 717 50.9 2,485 47.5 4,775 46.6
Female 2,028 56.3 693 49.1 2,748 52.5 5,469 53.4
Age (yr)
49 175 4.9 25 1.8 632 12.1 832 8.1
5059 348 9.7 119 8.4 685 13.1 1,152 11.2
6069 1,231 34.2 515 36.5 1,703 32.5 3,449 33.7
7079 1,419 39.4 601 42.6 1,672 32.0 3,692 36.0
80 428 11.9 150 10.6 541 10.3 1,119 10.9
1142 MANTILLA ET AL.
Anesthesiology, V 96, No 5, May 2002
in the 30 days after surgery, corresponding to an overall
event rate of 2.2% (myocardial infarction: 0.4%; pulmo-
nary embolism: 0.7%; deep venous thrombosis: 1.5%;
death: 0.5%). The overall frequency of adverse events
and the frequency of individual adverse events did not
change signicantly over the 10-yr period of study, with
the exception of myocardial infarction, for which there
was a slight increase over time (0.2% in 1986 and 1987,
and 0.6% in 1994 and 1995; P 0.004).
The frequencies of myocardial infarction, pulmonary
embolism, deep venous thrombosis, and death are pre-
sented in table 2 and gure 1, according to age and type
of procedure. The age- and sex-specic frequencies of
these events are presented in gure 2. The frequency of
myocardial infarction increased markedly with older age
(P 0.001) and was higher for male patients compared
with female patients (P 0.016, g. 2). For patients
aged 6069 yr, 7079 yr, and 80 yr or more, the corre-
sponding frequencies of myocardial infarction were 0.1,
0.4, and 1.3% for female patients and 0.4, 0.7, and 2.2%
for male patients. The median time to myocardial infarc-
tion was 1 day; 38 of 46 (83%) events occurred within
3 days; and 43 (93%) occurred within 14 days after the
operation. The frequency of pulmonary embolism was
similar for male and female patients but was increased in
older patients (P 0.002) and was found to be signi-
cantly different (P 0.001) across procedure types. For
patients aged 6069 yr, 7079 yr, and 80 yr or more, the
corresponding frequencies of pulmonary embolism
were 0.2, 0.8, and 0.9% for unilateral knee procedures;
1.0, 1.8, and 2.7% for bilateral knee procedures; and 0.4,
0.4, and 1.3% for hip procedures. In general, patients
undergoing bilateral knee procedures were observed to
have a frequency of pulmonary embolism nearly double
that of patients undergoing unilateral procedures (g. 1).
The median time to pulmonary embolism was 4 days; 45
of 68 (66%) events occurred within 7 days; and 53 (78%)
occurred within 14 days after the operation. The overall
frequency of clinically detected deep venous thrombosis
was 1.5%. The frequency of deep venous thrombosis
was not found to differ signicantly with age, sex, or
type of procedure. The median time to deep venous
Table 2. Frequency of Probable or Denite Myocardial Infarction, Pulmonary Embolism, Deep Venous Thrombosis, and Death
According to Age and Type of Procedure*
Event and Age Group
Unilateral Knee Bilateral Knee Hip Total
n % n % n % n %
Myocardial infarction (yr)
49 0 0.0 0 0.0 0 0.0 0 0.0
5059 0 0.0 0 0.0 1 0.1 1 0.1
6069 2 0.2 2 0.4 3 0.2 7 0.2
7079 7 0.5 4 0.7 9 0.5 20 0.5
80 1 0.2 6 4.0 11 2.0 18 1.6
All ages 10 0.3 12 0.9 24 0.5 46 0.4
Pulmonary embolism (yr)
49 0 0.0 0 0.0 1 0.2 1 0.1
5059 0 0.0 2 1.7 7 1.0 9 0.8
6069 3 0.2 5 1.0 7 0.4 15 0.4
7079 11 0.8 11 1.8 7 0.4 29 0.8
80 4 0.9 4 2.7 7 1.3 15 1.3
All ages 18 0.5 22 1.6 29 0.6 69 0.7
Deep venous thrombosis (yr)
49 1 0.6 0 0.0 10 1.6 11 1.3
5059 3 0.9 4 3.4 15 2.2 22 1.9
6069 14 1.1 9 1.7 22 1.3 45 1.3
7079 29 2.0 12 2.0 13 0.8 54 1.5
80 8 1.9 6 4.0 9 1.7 23 2.1
All ages 55 1.5 31 2.2 69 1.3 155 1.5
Death (yr)
49 0 0.0 0 0.0 0 0.0 0 0.0
5059 1 0.3 0 0.0 1 0.1 2 0.2
6069 1 0.1 0 0.0 5 0.3 6 0.2
7079 9 0.6 3 0.5 4 0.2 16 0.4
80 2 0.5 2 1.3 19 3.5 23 2.1
All ages 13 0.4 5 0.4 29 0.6 47 0.5
Any event (yr)
49 1 0.6 0 0.0 10 1.6 11 1.3
5059 4 1.1 4 3.4 16 2.3 24 2.1
6069 17 1.4 11 2.1 29 1.7 57 1.7
7079 41 2.9 18 3.0 22 1.3 81 2.2
80 10 2.3 10 6.7 31 5.7 51 4.6
All ages 73 2.0 43 3.0 108 2.1 224 2.2
* For each procedure type, the number of patients in each age group (i.e., the denominator for the percentage calculation) is presented in table 1.
1143 FREQUENCY OF ADVERSE EVENTS IN HIP OR KNEE SURGERY
Anesthesiology, V 96, No 5, May 2002
thrombosis was 7 days; 110 of 153 (72%) events oc-
curred within 14 days after the operation. Perioperative
mortality was similar for male and female patients and
was consistent across procedure types but increased
signicantly (P 0.001) with older age. The frequency
of death was less than 0.2% for patients aged less than
70 yr, 0.4% for patients aged between 70 and 79 yr, and
2.1% for patients aged 80 yr or more. The median time to
death was 9 days, with 30 of 47 (64%) events occurring
within 14 days after the operation. Thirteen (28%) of 46
patients who experienced probable or denite myocar-
dial infarction and 10 (14%) of 69 patients who experi-
enced probable or denite pulmonary embolism died
within 30 days after surgery. Of the 155 patients expe-
riencing deep venous thrombosis, there were 10 deaths,
all of which occurred in patients who also experienced
pulmonary embolism.
Overall, in these patients undergoing primary hip or
knee arthroplasty, the percentage who experienced one
or more of these adverse events (myocardial infarction,
pulmonary embolism, deep venous thrombosis, or
death) increased with older age. Of 5,433 patients aged
less than 70 yr, 1.7% experienced one or more of these
events. This percentage increased to 2.2% for 3,692
patients aged 7079 yr and to 4.6% for 1,119 patients
aged 80 yr or more.
Discussion
This review provides physicians involved in the peri-
operative care of arthroplasty patients with information
about the rate of clinically relevant perioperative mor-
bidity and mortality after major elective orthopedic
surgery of the lower extremities performed with con-
temporary operative and perioperative care. The fre-
quencies of myocardial infarction, pulmonary embolism,
and death were higher in older patients, particularly
those aged 70 yr or older. Given the increasing age of the
population, lower extremity joint replacement opera-
tions are now considered and performed in many older
patients with serious coexisting diseases. Therefore, an
accurate description of the risks associated with these
surgeries should help clinicians and their patients in the
decision regarding treatment options.
The risk of myocardial infarction, pulmonary embo-
lism, deep venous thrombosis, or death found in the
current study is in accordance with the results of several
recent studies.
3,8,14,15,36
Previous studies have consisted
mostly of small series or single surgeon case reports
without prospective case ascertainment. Consequently,
comparison with historical control studies proves inad-
equate for estimation of the event rate over time.
Perioperative myocardial infarction is a signicant
cause of morbidity and mortality in the noncardiac op-
erative population because of the high prevalence of risk
factors for coronary artery disease.
12,29,37
Major orthope-
dic operations are commonly performed in older pa-
tients, possibly with signicant coronary artery disease,
hypertension, and atherosclerosis.
13
The American Col-
lege of Cardiology/American Heart Association Task
Force suggests that the risk of overall cardiac morbidity
in the orthopedic population is intermediate, in the
order of 15%.
12
There are little data available in the
literature regarding the current frequency of periopera-
tive myocardial infarction after lower extremity arthro-
plasty operations. Marsch et al.
20
prospectively exam-
ined myocardial ischemia using perioperative Holter
monitoring and reported a frequency of myocardial in-
farction of 1.9% in 52 patients after total hip arthroplasty
operations. In the current study, we found a 0.4% fre-
quency of clinically relevant myocardial infarction
within 30 days after elective primary total hip or knee
Fig. 1. Frequency of myocardial infarction (MI), pulmonary
embolism (PE), deep venous thrombosis (DVT), or death within
30 days after primary total hip or knee arthroplasty according
to age and surgical procedure.
Fig. 2. Age- and gender-specic frequency of myocardial infarc-
tion (MI), pulmonary embolism (PE), deep venous thrombosis
(DVT), or death within 30 days after primary total hip or knee
arthroplasty.
1144 MANTILLA ET AL.
Anesthesiology, V 96, No 5, May 2002
arthroplasty operations. A clear age- and sex-specic
effect on frequency was evident. However, potential
differences in underlying comorbid diseases may con-
tribute to the sex effect on the rate of myocardial infarc-
tion and cannot be excluded.
The Fifth American College of Chest Physicians Con-
sensus Conference on antithrombotic therapy
26
evalu-
ated available literature and reported total prevalence
rates of deep venous thrombosis after hip replacement
surgery (including asymptomatic cases detected by
venography) between 45 and 57%, with proximal deep
venous thrombosis rates between 23 and 36%. Similarly,
total prevalence rates of deep venous thrombosis after
total knee replacement were reported between 40 and
84%, with proximal deep venous thrombosis rates of
920%. Total prevalence rates of pulmonary embolism
were 0.730% after hip replacement and 1.87% after
knee replacement surgeries.
26
In this same document,
prevalence rates for fatal pulmonary embolism were
reported between 0.34 and 6% after hip arthroplasty and
between 0.2 and 0.7% after knee arthroplasty. In the
current study, we found an overall frequency of clini-
cally signicant and symptomatic deep venous thrombo-
sis of 1.5% in patients treated with elective primary
lower extremity arthroplasty. This rate is certainly lower
than that reported when prospective evaluation of deep
venous thrombosis using venography is undertak-
en
16,18,19,21,24,25
but is comparable to previous reports
based on clinical symptoms.
1,7,9,10,1315
We found a 0.7%
frequency of clinically relevant pulmonary embolism
within 30 days after elective primary total hip or knee
arthroplasty operations, an incidence slightly lower than
that of earlier investigations. Importantly, despite the
successful reduction of asymptomatic thromboembolic
disease with the use of routine anticoagulation, an actual
reduction of clinically relevant adverse events has been
difcult to demonstrate in everyday medical practice.
36
Although there is a large amount of clinical data docu-
menting the efcacy and cost effectiveness of routine
thromboprophylaxis in patients undergoing elective to-
tal hip or knee replacement surgery,
26
it is likely that
selected patient populations might receive the most ben-
et from specic prophylactic measures.
36
For example,
in our study, patients undergoing bilateral knee replace-
ment procedures had a much higher frequency of pul-
monary embolism when compared with unilateral knee
or even hip replacement patients. However, the fre-
quency of death in patients treated with elective primary
bilateral knee arthroplasty was not different from that of
patients undergoing unilateral knee or hip replacement
operative procedures.
Our report is the largest, detailed, single-institution
study of perioperative morbidity and mortality after pri-
mary lower extremity arthroplasty. Comparison of the
rate of clinically relevant adverse events from study to
study and over time is complicated by the differing end
points and criteria used for diagnosis of adverse events.
A review of available studies does not show an obvious
reduction in event rates with time. However, it is impor-
tant to note that the population of patients considered as
candidates for elective arthroplasty operations has prob-
ably changed over time, and more patients who are
older, sicker, and at greater risk are offered elective
operations now than in the past. In addition, adverse
events are more likely to occur during the patients
hospital stay and subsequent rehabilitation. In the cur-
rent study, the median times to myocardial infarction,
pulmonary embolism, and death were 1, 4, and 9 days,
respectively. Identication of patients at risk for serious
complications and accurate knowledge of the timing of
adverse events may allow early diagnosis and interven-
tion through heightened surveillance.
There are limitations inherent to the design of this
study. The quality of the data, especially regarding
events, is dependent on the accuracy and completeness
of the clinical record. In fact, it is possible for some
adverse perioperative events, such as a nonQ-wave
myocardial infarction or small pulmonary embolus with-
out hemodynamic changes, to go unrecognized by the
physician in charge of the patients care. However, all
the data were collected prospectively, and the extent of
follow-up of patients undergoing arthroplasty surgery at
our institution is such that the likelihood of missing
clinically relevant adverse events is very small. In the
current study, a single person collected all data using
standardized data collection forms and strict criteria for
each adverse event. Distinct levels of diagnostic cer-
tainty were used according to the evidence present in
each diagnosis. We assume that all clinically relevant
events came to clinical attention and were noted on the
record and thus were available for analysis.
The applicability of our results, which represent a
large-volume academic center, to other clinical settings
is unknown. Although a relation between surgical vol-
ume and outcome has been suggested, the results are
conicting. Taylor et al.
6
reported a decreased 30-day
mortality rate after total hip arthroplasty in hospitals
with higher surgical volumes, but no attempt was made
to adjust for the presence of comorbidities or degree of
surgical difculty. Conversely, in a review of the Veter-
ans Health Administration multihospital healthcare sys-
tem, Khuri et al.
5
found that specialty and procedure
volume did not affect the risk-adjusted 30-day mortality
for eight commonly performed procedures of interme-
diate complexity, including total hip replacement.
Therefore, there are no denitive data to suggest that the
surgeons experience and surgical volume affect mortal-
ity. However, additional investigations are needed to
determine the role of surgical volume and patient co-
morbidities in perioperative morbidity, including myo-
cardial infarction, pulmonary embolism, and death.
1145 FREQUENCY OF ADVERSE EVENTS IN HIP OR KNEE SURGERY
Anesthesiology, V 96, No 5, May 2002
In conclusion, this study represents one of the largest
investigations evaluating the frequency of adverse peri-
operative morbidity and mortality in patients undergoing
lower extremity arthroplasty using current medical treat-
ment. The observed frequency of adverse events in this
patient population provides information that may be
helpful when counseling patients about the risks associ-
ated with elective primary lower extremity joint replace-
ment operations.
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