Reduction in Mortality following Elective Major Hip and Knee Surgery: A Systematic Review and Meta-Analysis

Abstract

Background Systematic reviews reporting time trends in mortality following major orthopaedic surgery are few and have limitations. They reported on only a fraction (< 15%) of the available data and did not investigate potential causes of the reduction in mortality.

Methods We searched PubMed for randomized trials and observational studies, published between 1950 and 2016, reporting on mortality within 3 months of elective total hip and knee replacement (THR/TKR). Mortality risks were estimated for each 5-year interval using a Poisson regression model and presented by study design and mode of prophylaxis. To estimate the mortality reduction unrelated to anti-thrombotic use, we performed a pooled analysis of four thromboprophylaxis strategies for which data spanned five decades.

Results We identified 255 eligible studies, which documented 31,604 deaths among 6,293,954 patients, and found a consistent decline in mortality irrespective of study design and mode of prophylaxis. Mortality declined from 1.15% pre-1980 to 0.24% post-2000, a 78.7% relative risk reduction (95% confidence interval [CI]: 74.7–82.1%) in randomized and cohort studies. Furthermore, our data showed a 74.4% (95% CI: 68.7–79.0%) relative reduction in mortality independent of the methods of prophylaxis, thereby indicating that improvements in peri-operative care unrelated to anti-thrombotic prophylaxis played a major role in such reduction.

Conclusion Mortality following elective THR/TKR has markedly declined over the past 50 years and is now low irrespective of which prophylactic agent is being used. Although anti-thrombotic prophylaxis may have contributed, other improvements in peri-operative care played a major role in the mortality reduction.

Keywords

mortality - hip replacement - knee replacement - thromboprophylaxis - peri-operative care

• References

• 1 Johnson R, Green JR, Charnley J. Pulmonary embolism and its prophylaxis following the Charnley total hip replacement. Clin Orthop Relat Res 1977; (127) 123-132
• 2 Waugh W. John Charnley: The Man and the Hip. Springer-Verlag London; 1990
• 3 Hunt LP, Ben-Shlomo Y, Clark EM. , et al; National Joint Registry for England, Wales and Northern Ireland. 90-day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis. Lancet 2013; 382 (9898): 1097-1104
• 4 Hunt LP, Ben-Shlomo Y, Clark EM. , et al; National Joint Registry for England and Wales. 45-day mortality after 467,779 knee replacements for osteoarthritis from the National Joint Registry for England and Wales: an observational study. Lancet 2014; 384 (9952): 1429-1436
• 5 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
• 6 Cram P, Lu X, Kaboli PJ. , et al. Clinical characteristics and outcomes of Medicare patients undergoing total hip arthroplasty, 1991-2008. JAMA 2011; 305 (15) 1560-1567
• 7 Berstock JR, Beswick AD, Lenguerrand E, Whitehouse MR, Blom AW. Mortality after total hip replacement surgery: a systematic review. Bone Joint Res 2014; 3 (06) 175-182
• 8 Murray DW, Britton AR, Bulstrode CJ. Thromboprophylaxis and death after total hip replacement. J Bone Joint Surg Br 1996; 78 (06) 863-870
• 9 Iorio A, Spencer FA, Falavigna M. , et al. Use of GRADE for assessment of evidence about prognosis: rating confidence in estimates of event rates in broad categories of patients. BMJ 2015; 350: h870
• 10 Basques BA, Toy JO, Bohl DD, Golinvaux NS, Grauer JN. General compared with spinal anesthesia for total hip arthroplasty. J Bone Joint Surg Am 2015; 97 (06) 455-461
• 11 Graves N, Wloch C, Wilson J. , et al. A cost-effectiveness modelling study of strategies to reduce risk of infection following primary hip replacement based on a systematic review. Health Technol Assess 2016; 20 (54) 1-144
• 12 Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg 2011; 112 (06) 1392-1402
• 13 Pearse EO, Caldwell BF, Lockwood RJ, Hollard J. Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism. J Bone Joint Surg Br 2007; 89 (03) 316-322
• 14 Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med 1988; 318 (18) 1162-1173
• 15 Kakkar W, Corrigan TP, Fossard DP. , et al. Prevention of fatal postoperative pulmonary embolism by low doses of heparin. An international multicentre trial. Lancet 1975; 2 (7924): 45-51
• 16 Sobieraj DM, Coleman CI, Tongbram V. , et al. Comparative effectiveness of low-molecular-weight heparins versus other anticoagulants in major orthopedic surgery: a systematic review and meta-analysis. Pharmacotherapy 2012; 32 (09) 799-808
• 17 Comparative Effectiveness of Pulmonary Embolism Prevention After Hip and Knee Replacement. ClinicalTrials.gov; 2018. Available at: https://clinicaltrials.gov/ct2/show/NCT02810704 . Accessed February 8, 2018
• 18 Chan NC, Siegal D, Lauw MN. , et al. A systematic review of contemporary trials of anticoagulants in orthopaedic thromboprophylaxis: suggestions for a radical reappraisal. J Thromb Thrombolysis 2015; 40 (02) 231-239
• 19 Bjørnarå BT, Gudmundsen TE, Dahl OE. Frequency and timing of clinical venous thromboembolism after major joint surgery. J Bone Joint Surg Br 2006; 88 (03) 386-391