European Journal of Cardiovascular Medicine

The gold standard surgical treatment for osteoarthritis of the hip and knee is total hip arthroplasty (THR) and total knee arthroplasty (TKA) respectively, which improves function, pain relief, and quality of life [1]. THA and TKA are expected to expand by 174% and 673%, respectively, by 2030, and 4 million total joint arthroplasties (TJA) are expected to be performed annually in the USA. Even though serious cardiac complications after TJA are thought to be very safe, with reported rates as low as 0.2 to 0.8%, this risk increases significantly when one considers the projected huge rise in arthroplasties in the future [2].

Cardiac complications are linked to higher hospital mortality, longer hospital stays, a higher rate of non-cardiac events, and higher health costs. They also constitute a significant cause of morbidity and mortality following total joint arthroplasty (TJA). Thus, it is becoming increasingly important to comprehend the dangers that lead to cardiac problems that are connected to THA and TKA [3].

The TJA population is getting older and more comorbid with conditions, especially diabetes and obesity, as a result of sedentary lifestyles and improvements in medical care that are extending life expectancy [4]. Navigating the rising prevalence of arthroplasty surgeries in a population with higher cardiovascular risk presents a growing problem in total joint arthroplasty [5].

The last ten years have seen a significant increase in the body of research identifying patient risk factors that increase the likelihood of cardiovascular complications. However, there are still a lot of risk variables about which there is disagreement and ambiguity [6].

We performed this study to assess risk factors associated with cardiac complications after total joint arthroplasty (TJA) of the hip and knee.

After considering the utility of the study and obtaining approval from the ethical review committee, we selected thirty-two patients age 25 to 70 years who underwent TJA and experienced a cardiac complication during the post operative period (myocardial infarction [MI], congestive heart failure [CHF], unstable angina, arrhythmia, symptomatic hypotension, or pulmonary embolism). Patients were monitored for up to 90 days following surgery.

Data such as name, age, etc. was recorded. Group I comprised of patients with TJA and cardiac complication and group II had healthy controls consisted of those who had a TJA and did not experience a cardiac complication during the surgical admission period. Controls were matched to the cases for age at surgery, year of surgery, and surgeon. Case and control status and identification of potential risk factors were ascertained by review of medical records. The results were compiled and subjected to statistical analysis using the Mann- Whitney U test. P value less than 0.05 was regarded as significant.

Table I Patients distribution

Age group 25-35 years had 3, 36-45 years had 5, 46-55 years had 10 and 56-70 years had 14 patients. The difference was significant (P< 0.05) (Table I, Graph I).

  Graph I Patients distribution

Table II Crude odds ratios (ORs) for the association between potential risk factors and cardiac complications

                 ORs – Odd ratios, CI- confidence interval

Group I had 20 males and group II had 18 males. Age >65 years were seen in 8 patients in group I and 7 in group II. Body mass index >30 was seen in 12 in group I and 14 in group II. Diabetes was seen in 4 in group I and 3 in group II, hypertension in 18 in group I and 16 in group II. History of CAD, MI, CHF, and/or valvular heart disease was seen in 5 in group I and 3 in group II, history of arrhythmia was seen in 4 in group I and 2 in group II. Abnormal rhythm on preoperative EKG was seen in 6 in group I and 3 in group II. Use of COX-2 inhibitor was seen in 7 in group I and 6 in group II. Use of NSAIDs was seen in 6 in group I and 7 in group II. Revision surgery was performed in 4 in group I and 3 in group II. Age >65 years [OR:1.78 (95%CI: 1.1-3.9)], history of arrhythmia [OR: 2.4 (95%CI: 1.7-4.2)], history of CAD, MI, CHF, and/or valvular heart disease [OR:2.3 (95%CI:1.5-3.8)], and revision surgery [OR:2.3 (95%CI:1.7-2.7)] were independent predictors of postoperative cardiac complications (Table II, Graph II).

Graph II

Total joint arthroplasty (TJA) is a beneficial procedure that can increase hip and knee arthritis patient’s activities and quality of life. Despite its nature and safety, it has been linked to various negative consequences that could jeopardize the procedure’s outcome [7].

Major complications corresponding to THA and TKA includes myocardial infarction (MI), cardiac arrest, cerebrovascular accidents (CVA), deep vein thrombosis (DVT), pulmonary embolism, and acute renal failure [8,9].

In the field of orthopaedics, THA and TKA are frequently performed surgical procedures that carries a high risk of peri and post-operative complications due to the patient’s advanced age and several associated diseases. Cardiovascular complications are the primary cause of death among all adverse events [10,12].

We performed this study to assess risk factors associated with cardiac complication after total joint arthroplasty (TJA) of the hip and knee. Age group 25-35 years had 3, 36-45 years had 5, 46-55 years had 10 and 56-70 years had 14 patients. Basilico et al. [11], identified the risk factors of cardiac problems after total joint replacement (TJR) surgery. There were 209 cases and 209 controls in the sample. A history of arrhythmia [OR: 2.4 (95%CI: 1.7-4.2)], history of CAD, MI, CHF, and/or valvular heart disease [OR:2.3 (95%CI:1.5-3.8)], and revision surgery [OR:2.3 (95%CI:1.7-2.7)] were independent predictors of postoperative cardiac complications. Age was linked to a greater risk of cardiac problems even when controls were age matched (within age groups) [OR :1.78 (95% CI: 1.1–3.9)].

It was observed that group I had 20 males and group II had 18 males. Age >65 years were seen in 8 patients in group I and 7 in group II. Body mass index >30 was seen in 12 in group I and 14 in group II. Diabetes was seen in 4 in group I and 3 in group II, hypertension in 18 in group I and 16 in group II. History of CAD, MI, CHF, and/or valvular heart disease was seen in 5 in group I and 3 in group II, history of arrhythmia was seen in 4 in group I and 2 in group II. Abnormal rhythm on preoperative EKG was seen in 6 in group I and 3 in group II. Use of COX-2 inhibitor was seen in 7 in group I and 6 in group II.

Elsiwy Y et al. [12], determined the risk factors for cardiac complications following total hip and total knee arthroplasty. This systematic review contained fifteen studies. The majority of research indicated a significant correlation between increasing age and a history of heart disease and the risk of cardiac complications. Obesity and heart complications did not show to be strongly associated. Although there is suggestive evidence linking male gender to an increased risk of cerebrovascular illness, the evidence for other risk variables was less apparent in the literature reviewed.

It was observed in our study that use of NSAIDs was seen in 6 in group I and 7 in group II. Revision surgery was performed in 4 in group I and 3 in group II. Age >65 years [OR:1.8 (95%CI:1.1-3.5)], history of arrhythmia [OR:2.5 (95%CI:1.7-4.3)], history of CAD, MI, CHF, and/or valvular heart disease [OR:2.1 (95%CI:1.5-3.5)], and revision surgery [OR:2.1 (95%CI:1.7-2.9)] were independent predictors of postoperative cardiac complications.

Blom A et al. [13], found the fatality rate after 90 days in 1727 primary total hip arthroplasties in an unselected sequential series of patients who had not undergone chemothromboprophylaxis on a regular basis. Ninety days later, the death rate was 17/1727 (1%). In patients under 70 years of age, the 90-day death rate was 2.5%; in patients between 70 and 80 years of age, it was 1.3%. Four patients passed away after cerebrovascular episodes, two from pulmonary embolism, and seven from ischemic heart disease. Non-vascular causes of death claimed four victims. Ischemic heart disease outweighed cerebrovascular events, which in turn outnumbered pulmonary embolisms (7 vs. 4 vs. 2) among the vascular deaths.

According to Singh et al. [14], there are no reliable indicators of thromboembolism in total joint arthroplasty patients.

Less than 5% of cases of acute hypotension are associated with the use of Polymethylmethacrylate (PMMA) cement [15]. 

An unusual side effect after bilateral metal-on-metal (MoM) THA was described by Martin et al. [16], as cardiac cobaltism. They described a death instance linked to Co toxicity brought on by bilateral MoM THA.

Total joint arthroplasty (TJA) presents challenges for the involved specialists due to the nature of the patients undergoing such operations (elderly patients with osteoporosis and scarce cardiopulmonary reserve), the unclear genesis of complications, and the lack of agreement on what counts as appropriate monitoring during surgery.

Risk assessment for postoperative complications in orthopedic surgery is critical for minimizing negative outcomes. This study emphasizes the importance of considering risk factors before undergoing THA and TKA surgery.

Our study can be utilized to educate the patients as recognize their illness, the therapies that are available, what those treatments entail, and any potential negative consequences.

Limitations of this study

The small sample size is a limitation of this study. A larger sample size is required for further analysis.

Total joint arthroplasty (TJA) is a beneficial procedure that can increase hip and knee arthritis patient’s activities and quality of life. Despite its nature and safety, it has been linked to various negative consequences that could jeopardize the procedure’s outcome [7].

Major complications corresponding to THA and TKA includes myocardial infarction (MI), cardiac arrest, cerebrovascular accidents (CVA), deep vein thrombosis (DVT), pulmonary embolism, and acute renal failure [8,9].

In the field of orthopaedics, THA and TKA are frequently performed surgical procedures that carries a high risk of peri and post-operative complications due to the patient’s advanced age and several associated diseases. Cardiovascular complications are the primary cause of death among all adverse events [10,12].

We performed this study to assess risk factors associated with cardiac complication after total joint arthroplasty (TJA) of the hip and knee. Age group 25-35 years had 3, 36-45 years had 5, 46-55 years had 10 and 56-70 years had 14 patients. Basilico et al. [11], identified the risk factors of cardiac problems after total joint replacement (TJR) surgery. There were 209 cases and 209 controls in the sample. A history of arrhythmia [OR: 2.4 (95%CI: 1.7-4.2)], history of CAD, MI, CHF, and/or valvular heart disease [OR:2.3 (95%CI:1.5-3.8)], and revision surgery [OR:2.3 (95%CI:1.7-2.7)] were independent predictors of postoperative cardiac complications. Age was linked to a greater risk of cardiac problems even when controls were age matched (within age groups) [OR :1.78 (95% CI: 1.1–3.9)].

It was observed that group I had 20 males and group II had 18 males. Age >65 years were seen in 8 patients in group I and 7 in group II. Body mass index >30 was seen in 12 in group I and 14 in group II. Diabetes was seen in 4 in group I and 3 in group II, hypertension in 18 in group I and 16 in group II. History of CAD, MI, CHF, and/or valvular heart disease was seen in 5 in group I and 3 in group II, history of arrhythmia was seen in 4 in group I and 2 in group II. Abnormal rhythm on preoperative EKG was seen in 6 in group I and 3 in group II. Use of COX-2 inhibitor was seen in 7 in group I and 6 in group II.

Elsiwy Y et al. [12], determined the risk factors for cardiac complications following total hip and total knee arthroplasty. This systematic review contained fifteen studies. The majority of research indicated a significant correlation between increasing age and a history of heart disease and the risk of cardiac complications. Obesity and heart complications did not show to be strongly associated. Although there is suggestive evidence linking male gender to an increased risk of cerebrovascular illness, the evidence for other risk variables was less apparent in the literature reviewed.

It was observed in our study that use of NSAIDs was seen in 6 in group I and 7 in group II. Revision surgery was performed in 4 in group I and 3 in group II. Age >65 years [OR:1.8 (95%CI:1.1-3.5)], history of arrhythmia [OR:2.5 (95%CI:1.7-4.3)], history of CAD, MI, CHF, and/or valvular heart disease [OR:2.1 (95%CI:1.5-3.5)], and revision surgery [OR:2.1 (95%CI:1.7-2.9)] were independent predictors of postoperative cardiac complications.

Blom A et al. [13], found the fatality rate after 90 days in 1727 primary total hip arthroplasties in an unselected sequential series of patients who had not undergone chemothromboprophylaxis on a regular basis. Ninety days later, the death rate was 17/1727 (1%). In patients under 70 years of age, the 90-day death rate was 2.5%; in patients between 70 and 80 years of age, it was 1.3%. Four patients passed away after cerebrovascular episodes, two from pulmonary embolism, and seven from ischemic heart disease. Non-vascular causes of death claimed four victims. Ischemic heart disease outweighed cerebrovascular events, which in turn outnumbered pulmonary embolisms (7 vs. 4 vs. 2) among the vascular deaths.

According to Singh et al. [14], there are no reliable indicators of thromboembolism in total joint arthroplasty patients.

Less than 5% of cases of acute hypotension are associated with the use of Polymethylmethacrylate (PMMA) cement [15]. 

An unusual side effect after bilateral metal-on-metal (MoM) THA was described by Martin et al. [16], as cardiac cobaltism. They described a death instance linked to Co toxicity brought on by bilateral MoM THA.

Total joint arthroplasty (TJA) presents challenges for the involved specialists due to the nature of the patients undergoing such operations (elderly patients with osteoporosis and scarce cardiopulmonary reserve), the unclear genesis of complications, and the lack of agreement on what counts as appropriate monitoring during surgery.

Risk assessment for postoperative complications in orthopedic surgery is critical for minimizing negative outcomes. This study emphasizes the importance of considering risk factors before undergoing THA and TKA surgery.

Our study can be utilized to educate the patients as recognize their illness, the therapies that are available, what those treatments entail, and any potential negative consequences.

Limitations of this study

The small sample size is a limitation of this study. A larger sample size is required for further analysis.

As the incidence of THA and TKA keep rising, more knowledge on the risk factors for cardiac complications is required. Risk factors for cardiac complication after total joint arthroplasty (TJA) of the hip and knee include increasing age, underlying heart disease, a history of heart disease, and previous history of thromboembolism. Other significant risk factors, including as diabetes, hypertension, gender, and smoking history, have conflicting findings in this study and need more research.

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