The growing demand for THA [16
] coupled with age and increase in comorbidities of patients undergoing the procedure [12
] warrants investigation of its current perioperative mortality rate. The primary focus of this paper was to determine overall mortality and causes of death at 30 and 90 days for patients undergoing THA. Secondly, we chose to compare mortality rates of primary and revision arthroplasty. Lastly, we compared mortality rates among different age groups within our study. With these goals in mind, we recognize this study has some limitations. First, few autopsies were performed, thus limiting the validity of the listed causes of death on certificates. Furthermore, we had to rely on ICD-10 codes and death certificates for cause of death information and it is possible that this information was not always accurate. Despite these limitations, we provided the most objective available causes of death, and the reported causes of death were consistent and accurate with information and data collected from our hospital records. Further, this is a relatively large study reporting early mortality for consecutive patients undergoing uncemented THA under regional anesthesia and modern pain management and rehabilitation in a single institution. Every effort was made to determine the status of each patient in this study, which included contacting national and state registries. Finally, all patients were subjected to nearly the same surgical, anesthesia, and rehabilitation protocols. The latter minimized the influence of a confounding variable such as anticoagulation protocols and the type of anesthesia.
Previous studies have reported very low (0.24% to 1%) [3
] perioperative mortality for elective primary THA (Table ). Our study supports these findings with two intraoperative deaths and overall mortality rates of 0.24% (18 of 7478) and 0.55% (41 of 7478) at 30 and 90 days, respectively. Consistent with other reports [3
], we also found the most common cause of death to be cardiovascular-related.
Early mortality after primary and revision THA
In addition to reaffirming the effectiveness and safety of THA, our study results suggest that modern advances in surgery, anesthesia, and rehabilitation have helped keep mortality as low as previously reported despite early hospital discharges, more aggressive rehab protocols, and operations being performed in patients who are older and more infirm. Several improvements in orthopaedic practice are responsible for the low reported mortality rate in this study. First, procedures were completed in a high-volume hospital by experienced surgeons specializing in total joint arthroplasty. A high hospital case load and surgeon experience lower perioperative mortality and in-hospital deaths [9
]. Second, improvements in anesthesia and pain management have reduced mortality and improve outcome after THA. The use of hypotensive, neuroaxial anesthesia has reduced mortality from cardiorespiratory complications [11
]. Finally, the use of multimodal anesthesia and analgesia for perioperative care and pain management has shown improvement in functional outcome and accelerated patient discharge [1
], which may indirectly help lower mortality. Changes in surgical practices and implantable devices have also helped reduce mortality after THA. A previous study reported the use of uncemented components decreases intraoperative death resulting from prevention of bone cement implantation syndrome [32
]. Furthermore, studies have demonstrated increased implant survivorship for noncemented devices [4
]. Increased implant lifetime will decrease the need for reoperation and reduce the increased risk of mortality which accompanies revision surgery. In addition, efforts made to decrease intraoperative time have helped limit blood loss, infection, and intraoperative complications [37
]. The prophylactic uses of first-generation cephalosporin antibiotics and low-dose Coumadin (warfarin, Bristol-Myers Squibb Company, Princeton, NJ) anticoagulation have reduced infection and cardiovascular-related causes of death. Additionally, it is of importance to note the low incidence of thromboembolic events resulting in death (two of 7478). We found our data regarding death from thromboembolism to be comparable to previous studies [3
]. Of note, our study used a lower INR than the currently published ACCP guideline. We find these data interesting and believe they warrant a more controlled study in the future.
When comparing rates of primary and revision arthroplasty and respective age groups, our data show that subjects less than 65 years old receiving primary elective THA had the lowest mortality of 0.03% (one of 3492), while those over 85 years old and receiving revision THA had the highest mortality of 6.25% (four of 64). These mortality rates are as low as those previously published [3
]. In addition to aforementioned advances in surgical, anesthesia, and rehabilitation techniques, rigorous preoperative screening and identification of high-risk patients for complications, especially cardiovascular complications and near-fatal arrhythmias, are extremely important and have been fundamental in reducing mortality after THA at our institution [31
]. Advances in rehabilitation strategies have recently received more attention and may help to reduce complications and perioperative mortality after THA. Aggressive postoperative rehabilitation strategies and home exercise rehabilitation improve short-term outcome after surgery by improving the patient’s functional status and preventing complications such as dislocation [17
]. Although decreases in mortality have not been directly attributed to rehabilitation strategies, it is certain they help improve patient outcome and function and thus influence outcome after THA. More studies are needed to establish their relationship and benefit.
Our data support the fact that hip arthroplasty performed using modern techniques appears extremely safe; yet, despite rigorous screening methods, deaths still occur. Shorter lengths of hospital stay make prevention of postoperative complications increasingly difficult to prevent. Also, the preponderance of cardiovascular-related deaths is reason to place more emphasis on preoperative screening and postoperative monitoring of high-risk patients to prevent cardiovascular complications and related deaths in the future. Further reductions in mortality will be attributed to our ability to identify, manage, and treat patients with risk factors for cardiovascular complications. As THA is performed more frequently in older and sicker patients, it is important we continue to monitor its associated mortality.