In-hospital Mortality after Septic Revision TKA: Analysis of the New York and Florida State Inpatient Databases

30-Days to 10-Years Mortality Rates following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of the Last Decade (2011-2021)

Mortality data following primary total knee arthroplasty (TKA) beyond 1-year postoperative time period is sparse. This systematic review and meta-analysis aimed to: (1) estimate contemporary mortality rates at 30 days, 90 days, 1 year, 5 years, and 10 years following primary TKA; and (2) identify risk factors and causes of mortality following TKA. PubMed, MEDLINE, Cochrane, EBSCO host, and Google Scholar databases were queried from January 1, 2011 to October 30, 2021 for all studies reporting mortality rates following primary TKA. A meta-analysis of proportions was conducted using a random-effects model to ascertain pooled mortality rates (95% confidence interval [CI]). Meta-regression was utilized to account for confounding effects on mortality rates due to the study's country of origin, median date of study data, average patient age, and patient gender ratios, with a level of significance maintained at p-value <0.05. A total of 44 articles were included in quantitative synthesis. The pooled 30-day mortality rate was 0.14% (95% CI:0.05-0.22%; n = 1,817,647). The pooled 90-day mortality rate was 0.35% (95% CI:0.0.28-0.43%; n = 1,641,974). The pooled 1-year mortality rate was 1.1% (95% CI:0.71-1.49%; n = 1,178,698). The pooled 5-year mortality rate was 5.38% (95% CI:4.35-6.42%; n = 597,041). The pooled 10-year mortality rate was 10.18% (95% CI:7.78-12.64%; n = 815,901). Our 30-day mortality rate was lower than previously reported. The most common causes of death at all time points were due to cardiac disease, cerebrovascular disease, and malignancy. Obesity demonstrated mixed effects on long-term mortality rates. Overall mortality rates of TKA remain low worldwide at all time points and immediate postoperative mortality rates continue to fall. Compared to symptomatic knee osteoarthritic patients reported in the literature, TKA patients qualitatively exhibited lower mortality rates, which may support the value of TKA in improving quality of life without associated excess mortality. Future long-term mortality studies should be conducted to account for geographical variability in mortality rates and further elucidate modifiable risk factors associated with mortality among TKA patients.

A mapping review on preoperative prognostic factors and outcome measures of revision total knee arthroplasty

To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration. We performed a systematic literature search in MEDLINE, Embase, and Web of Science. The search string included multiple synonyms of the following keywords: "revision TKA", "outcome" and "prognostic factor". We searched for studies assessing the association between at least one prognostic factor and at least one outcome measure after rTKA surgery. Data on sample size, study design, prognostic factors, outcomes, and the direction of the association was extracted and included in an evidence map. After screening of 5,660 articles, we included 166 studies reporting prognostic factors for outcomes after rTKA, with a median sample size of 319 patients (30 to 303,867). Overall, 50% of the studies reported prospectively collected data, and 61% of the studies were performed in a single centre. In some studies, multiple associations were reported; 180 different prognostic factors were reported in these studies. The three most frequently studied prognostic factors were reason for revision (213 times), sex (125 times), and BMI (117 times). Studies focusing on functional scores and patient-reported outcome measures as prognostic factor for the outcome after surgery were limited (n = 42). The studies reported 154 different outcomes. The most commonly reported outcomes after rTKA were: re-revision (155 times), readmission (88 times), and reinfection (85 times). Only five studies included costs as outcome. Outcomes and prognostic factors that are routinely registered as part of clinical practice (e.g. BMI, sex, complications) or in (inter)national registries are studied frequently. Studies on prognostic factors, such as functional and sociodemographic status, and outcomes as healthcare costs, cognitive and mental function, and psychosocial impact are scarce, while they have been shown to be important for patients with osteoarthritis.

Understanding the 30-day mortality burden after revision total knee arthroplasty

Background

In revision total knee arthroplasty (TKA), information regarding perioperative mortality risk is essential for careful decision-making. This study aimed to elucidate the (1) overall 30-day mortality rate and (2) 30-day mortality rate stratified by age, comorbidity, and septic vs aseptic failure after revision TKA.

Methods

The American College of Surgeons National Surgical Quality Improvement Program was reviewed for all patients undergoing revision TKA from 2011 to 2019. A total of 32,354 patients who underwent TKA were identified and categorized as mortality (n = 115) or mortality-free (n = 32,239). Patient characteristics were compared between cohorts and further stratified by septic and aseptic failure.

Results

The overall 30-day mortality rate was 0.36%. The percentage of deaths per age group (normalized per 1000) was 0% (18-29 years), 0% (30-39 years), 0.18% (40-49 years), 0.13% (50-59 years), 0.14% (60-69 years), 0.40% (70-79 years), 1.25% (80-89 years), and 6.93% (90+ years). The percentage of deaths per American Society of Anesthesiologists (ASA) class was 0.30% (ASA 1), 0.06% (ASA 2), 0.39% (ASA 3), 2.41% (ASA 4), and 14.29% (ASA 5). Septic revision (P < .001), general anesthesia (P < .001), body mass index ≤ 24.9 (P < .001), and insulin-dependent diabetes (P = .039) were associated with an increased risk of mortality.

Conclusions

Increasing age, greater comorbidity burden, underweight or normal body mass index, insulin-dependent diabetes, septic revision, and general anesthesia were all associated with an increased risk of mortality after revision TKA. Notably, 1 in 80 patients aged 80-89 years died after revision TKA compared to 1 in 720 patients aged 60-69 years. Patients who underwent septic revision had a 4-fold increase in mortality compared to aseptic revision. Our stratified assessment of mortality provides a more individualized estimation of risk that can be used for patient counseling in revision TKA.