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Total Joint Arthroplasty: When Do Fatal or Near-Fatal Complications Occur?
Javad Parvizi, MD1; Alan Mui, MD1; James J. Purtill, MD1; Peter F. Sharkey, MD1; William J. Hozack, MD1; Richard H. Rothman, MD, PhD1
1 Rothman Institute of Orthopedics, Thomas Jefferson Hospital, 925 Chestnut Street, Philadelphia, PA 19107. E-mail address for J. Parvizi: parvj@aol.com
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Disclosure: The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Rothman Institute of Orthopedics, Thomas Jefferson University, Philadelphia, Pennsylvania

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Jan 01;89(1):27-32. doi: 10.2106/JBJS.E.01443
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Background: With the recent trend toward minimally invasive total joint arthroplasty and the increased emphasis on faster recovery and shorter hospital stays, it has become increasingly important to recognize the timing and severity of the various complications associated with elective total joint arthroplasty to ensure that early patient discharge is a safe practice.

Methods: We evaluated the systemic and local complications associated with primary unilateral lower-extremity arthroplasties performed during one year in 1636 patients. A total of 966 patients had a primary total hip arthroplasty, and 670 had a primary total knee arthroplasty. All complications that occurred in the hospital and for six weeks following the index surgery were recorded. The circumstances leading to the complications and the details of the therapeutic intervention for each complication were recorded. Analyses were performed to predict the factors that predispose patients to serious complications.

Results: One patient (0.06%) in the cohort died during the hospital stay. There were a total of 104 major (life-threatening) complications, including cardiac arrest (one), tachyarrhythmia (thirty-three), pulmonary edema or congestive heart failure (ten), myocardial infarction (six), hypotensive crisis (four), pulmonary embolus (twenty-five), acute renal failure (fourteen), stroke (six), bowel obstruction or perforation (three), and pneumothorax (one). There were seventeen major local complications. Ninety-four (90%) of the major complications occurred within four days after the index surgery. Although older age, increased body mass, and preexistent comorbidities were important predisposing factors for serious medical complications, 58% of the patients who had life-threatening complications develop had no identifiable predisposing factors.

Conclusions: This study demonstrated that most of the complications of lower-extremity total joint replacement occur within the time-frame of the typical hospital stay. Given the serious nature of some of these complications and the inability to identify many of the patients who may be at risk, we caution against early discharge of patients from the hospital after elective total joint arthroplasty in the lower extremity.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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