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Early Mortality After Total Hip Arthroplasty In Sweden
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Every year 16 000 individuals receive a total hip arthroplasty (THA) in Sweden. Even though THA is a common procedure, adverse events do occur. The most dramatic complication is death in the postoperative phase. The overall aim of this thesis was to describe and investigate early mortality after THA in Sweden.

Sweden has an ideal platform for national observational registry studies, thanks to the use of personal identity numbers. Operation-specific information was collected from the Swedish Hip Arthroplasty Register, medical information from the National Board of Health and Welfare, and socioeconomic information was collected from Statistics Sweden. Main outcome was 90-day mortality.

Study I was a prospective observational register study investigating the risk of mortality after a simultaneous bilateral THA compared with staged bilateral THA. There was no clinically relevant difference in early postoperative mortality between the two groups.

Studies II and III were nation-wide matched cohort studies, with adjustment for comorbidity and socioeconomic background. Adjusted early mortality in femoral neck fracture patients receiving a THA is about double compared with a matched control population. Young (60-69 years) femoral neck fracture patients receiving a THA have a low absolute mortality risk, while those who are older than 80 years with a higher degree of medical comorbidity run a high risk of early death (II). In study III healthier, younger patients with higher socioeconomic status tended to be selected for cementless THA, resulting in selection bias. Even after accounting for this bias, however, there remains a small absolute and adjusted increase in the risk of death within 14 days after elective THA surgery using fully cemented implants.

Study IV was a nationwide prospective cohort study comparing different comorbidity measures in terms of predicting early postoperative mortality after THA. A less data-demanding comorbidity measure is better at predicting 90-day mortality than more commonly used coding algorithms.

In conclusion, socioeconomic background and the presence of comorbidities have an important influence on early mortality after THA, while the type of fixation is of less importance. Future mortality studies could benefit from the use of data that are routinely collected, and thus avoid the logistically complicated procedure now necessary to merge national databases.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2017. , 63 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1309
Keyword [en]
early mortality, total hip replacement, total hip arthroplasty, comorbidity, socioeconomic factor, cemented
National Category
Medical and Health Sciences
Research subject
Orthopaedics
Identifiers
URN: urn:nbn:se:uu:diva-316989ISBN: 978-91-554-9842-9 (print)OAI: oai:DiVA.org:uu-316989DiVA: diva2:1079500
Public defence
2017-04-29, Linnésalen, Museum Gustavianum, Akademigatan 3, Uppsala, 13:00 (English)
Opponent
Supervisors
Available from: 2017-04-07 Created: 2017-03-08 Last updated: 2017-04-21
List of papers
1. Early postoperative mortality after simultaneous or staged bilateral primary total hip arthroplasty: an observational register study from the swedish Hip arthroplasty register
Open this publication in new window or tab >>Early postoperative mortality after simultaneous or staged bilateral primary total hip arthroplasty: an observational register study from the swedish Hip arthroplasty register
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2015 (English)In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 16, 77Article in journal (Refereed) Published
Abstract [en]

Background: Approximately a fifth of all total hip arthroplasty (THA) patients suffers from bilateral osteoarthritis of the hip. It is unclear whether mortality risks differ between simultaneous bilateral THA and staged bilateral THA. We investigated mortality after simultaneous THA compared with staged bilateral THA in the largest cohort hitherto reported. Methods: The 42,238 patients reported to have received bilateral primary THA from 1992 to 2012 in the Swedish Hip Arthroplasty Register were included. Tumours and fractures as underlying diagnoses were excluded. The time interval between the first and second THA was divided into four categories or treated as a continuous variable. Unadjusted survival was calculated according to Kaplan-Meier and adjusted Cox regression models were fitted in order to calculate crude and adjusted hazard ratios (HR) for the risk of death within different time frames. Results: Patients selected for simultaneous bilateral surgery were younger, more often male, and had lower ASA (American Society of Anesthesiologists) class than patients receiving staged procedures. The adjusted 90-day mortality after the second procedure did not differ between the four investigated groups (simultaneous bilateral [HR 1.3, CI 0.5-3.3], surgeries within 6 months [HR 1.1, CI 0.6-2.0], surgeries between 7 and 12 months [HR 0.7, CI 0.4-1.2], with second surgery after > 12 months as the reference group). For patients older than 75 years, men, patients with ASA class 3 or above, and for patients with rheumatoid arthritis (RA) the 90-day mortality was increased. The unadjusted risk of implant revision of any hip was slightly higher for patients with simultaneous bilateral THA compared to those with staged procedure within one year, but after adjustment for age, gender, diagnosis and implant fixation these differences were no longer statistically significant. Conclusion: There were no clinically relevant differences in early postoperative mortality between simultaneous and staged bilateral surgery in healthy patients. Advanced age, RA, a high ASA class and male sex increased the risk of death within 90 days. There may be an issue with enhanced risk of implant revision in patients with simultaneous bilateral THA that needs to be explored further.

Keyword
Postoperative mortality, Perioperative mortality, Simultaneous bilateral total hip arthroplasty, Register, Registry, Total hip replacement, One-stage bilateral THR/THA, Two-stage bilateral THR/THA
National Category
Orthopedics
Identifiers
urn:nbn:se:uu:diva-252170 (URN)10.1186/s12891-015-0535-0 (DOI)000352609400001 ()25887667 (PubMedID)
Note

Erratum in BMC Musculoskeletal Disorders 2015:16, 263, doi:10.1186/s12891-015-0717-9.

Available from: 2015-05-06 Created: 2015-05-04 Last updated: 2017-03-08Bibliographically approved
2. Early mortality and morbidity after total hip arthroplasty in patients with femoral neck fracture
Open this publication in new window or tab >>Early mortality and morbidity after total hip arthroplasty in patients with femoral neck fracture
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2016 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 87, no 6, 560-566 p.Article in journal (Refereed) Published
Abstract [en]

Background and purpose - Early postoperative mortality is relatively high after total hip arthroplasty (THA) that has been performed due to femoral neck fracture. However, this has rarely been investigated after adjustment for medical comorbidity and comparison with the mortality in an age-matched population. We therefore assessed early mortality in hip fracture patients treated with a THA, in the setting of a nationwide matched cohort study.

Patients and methods - 24,699 patients who underwent THA due to a femoral neck fracture between 1992 and 2012 were matched with 118,518 controls. Kaplan-Meier survival analysis was used to calculate cumulative unadjusted survival, and Cox regression models were fitted to compute hazard ratios (HRs) and 95% confidence intervals (CIs), with adjustment for age, sex, comorbidity, and socioeconomic background.

Results - 90-day survival was 96.3% (95% CI: 96.0-96.5) for THA cases and 98.7% (95% CI: 98.6-98.8) for control individuals, giving an adjusted HR of 2.2 (95% CI: 2.0-2.4) for THA cases compared to control individuals. Comorbidity burden increased in THA cases over time, but the adjusted risk of death within 90 days did not differ statistically significantly between the time periods investigated (1992-1998, 1999-2005, and 2006-2012). A Charlson comorbidity index of 3 or more, an American Society of Anesthesiologists (ASA) grade of 3 and above, male sex, an age of 80 years and above, an income below the first quartile, and a lower level of education were all associated with an increased risk of 90-day mortality.

Interpretation - The adjusted early mortality in femoral neck fracture patients who underwent THA was about double that in a matched control population. Patients with femoral neck fracture but with no substantial comorbidity and an age of less than 80 years appear to have a low risk of early death. Patients older than 80 years and those with a Charlson comorbidity index of more than 2 have a high risk of early death, and such patients would perhaps benefit from treatment strategies other than THA, but this should be investigated further.

National Category
Orthopedics
Identifiers
urn:nbn:se:uu:diva-309086 (URN)10.1080/17453674.2016.1234869 (DOI)000388757800005 ()27649030 (PubMedID)
Available from: 2016-12-02 Created: 2016-12-02 Last updated: 2017-03-08Bibliographically approved
3. Risk of early mortality after cemented compared with cementless total hip arthroplasty: a nationwide matched cohort study
Open this publication in new window or tab >>Risk of early mortality after cemented compared with cementless total hip arthroplasty: a nationwide matched cohort study
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2017 (English)In: The Bone & Joint Journal, ISSN 2049-4394, E-ISSN 2049-4408, Vol. 99-B, no 1, 37-43 p.Article in journal (Refereed) Published
Abstract [en]

Aims It has been suggested that cemented fixation of total hip arthroplasty (THA) is associated with an increased peri-operative mortality compared with cementless THA. Our aim was to investigate this through a nationwide matched cohort study adjusting for age, comorbidity, and socioeconomic background. Patients and Methods A total of 178 784 patients with osteoarthritis who underwent either cemented or cementless THA from the Swedish Hip Arthroplasty Register were matched with 862 294 controls from the general population. Information about the causes of death, comorbidities, and socioeconomic background was obtained. Mortality within the first 90 days after the operation was the primary outcome measure. Results Patients who underwent cemented THA had an increased risk of death during the first 14 days compared with the controls (hazard ratio (HR) 1.3, confidence interval (CI) 1.11 to 1.44), corresponding to an absolute increase in risk of five deaths per 10 000 observations. No such early increase of risk was seen in those who underwent cementless THA. Between days 15 and 29 the risk of mortality was decreased for those with cemented THA (HR 0.7, CI 0.62 to 0.87). Between days 30 and 90 all patients undergoing THA, irrespective of the mode of fixation, had a lower risk of death than controls. Patients selected for cementless fixation were younger, healthier and had a higher level of education and income than those selected for cemented THA. A supplementary analysis of 16 556 hybrid THAs indicated that cementation of the femoral component was associated with a slight increase in mortality up to 15 days, whereas no such increase in mortality was seen in those with a cemented acetabular component combined with a cementless femoral component. Conclusion This nationwide matched cohort study indicates that patients receiving cemented THA have a minimally increased relative risk of early mortality that is reversed from day 15 and thereafter. The absolute increase in risk is very small. Our findings lend support to the idea that cementation of the femoral component is more dangerous than cementation of the acetabular component.

National Category
Orthopedics
Research subject
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-314962 (URN)10.1302/0301-620X.99B1 (DOI)000393669400008 ()28053255 (PubMedID)
Available from: 2017-02-07 Created: 2017-02-07 Last updated: 2017-03-31Bibliographically approved
4. Prediction of 90-day mortality after major surgery made simpler: An analysis of different comorbidity measures based on 38,735 patients from the Swedish Hip Arthroplasty Register
Open this publication in new window or tab >>Prediction of 90-day mortality after major surgery made simpler: An analysis of different comorbidity measures based on 38,735 patients from the Swedish Hip Arthroplasty Register
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(English)Manuscript (preprint) (Other academic)
National Category
Orthopedics
Identifiers
urn:nbn:se:uu:diva-314963 (URN)
Available from: 2017-02-07 Created: 2017-02-07 Last updated: 2017-03-08

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