Skip to main content

Advertisement

SpringerLink
Log in

Impact of Chronic Obstructive Pulmonary Disease on Outcomes After Total Joint Arthroplasty: A Meta-analysis and Systematic Review

  • Review Article
  • Published:
Indian Journal of Orthopaedics Aims and scope Submit manuscript

Abstract

Background

Comorbid chronic obstructive pulmonary disease (COPD) is increasingly common and may have an adverse impact on outcomes in patients undergoing total joint arthroplasty (TJA) of lower extremity. The purpose of this meta-analysis is to compare the postoperative complications between COPD and non-COPD patients undergoing primary TJA including total hip and knee arthroplasty.

Methods

PubMed, EMBASE, and Cochrane Library were systematically searched for relevant studies published before December 2021. Postoperative outcomes were compared between patients with COPD versus those without COPD as controls. The outcomes were mortality, re-admission, pulmonary, cardiac, renal, thromboembolic complications, surgical site infection (SSI), periprosthetic joint infection (PJI), and sepsis.

Results

A total of 1,002,779 patients from nine studies were finally included in this meta-analysis. Patients with COPD had an increased risk of mortality (OR [odds ratio] = 1.69, 95% confidence interval [CI] 1.42–2.02), re-admission (OR = 1.54, 95% CI 1.38–1.71), pulmonary complications (OR = 2.73, 95% CI 2.26–3.30), cardiac complications (OR = 1.40, 95% CI 1.15–1.69), thromboembolic complications (OR = 1.21, 95% CI 1.15–1.28), renal complications (OR = 1.50, 95% CI 1.14–1.26), SSI (OR = 1.23, 95% CI 1.18–1.30), PJI (OR = 1.26, 95% CI 1.15–1.38), and sepsis (OR = 1.36, 95% CI 1.22–1.52).

Conclusion

Patients with comorbid COPD showed an increased risk of mortality and postoperative complications following TJA compared with patients without COPD. Therefore, orthopedic surgeons can use the study to adequately educate these potential complications when obtaining informed consent. Furthermore, preoperative evaluation and medical optimization are crucial to minimizing postoperative complications from arising in this difficult-to-treat population.

Level of evidence

Level III.

Registration

None.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data availability

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Abbreviations

TJA:

Total joint arthroplasty

THA:

Total hip arthroplasty

TKA:

Total knee arthroplasty

COPD:

Chronic obstructive pulmonary disease

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

LOS:

Length of stay

AMI:

Acute myocardial infarction

CVA:

Cerebrovascular accident

DVT:

Deep vein thrombosis

PE:

Pulmonary embolism

PRI:

Progressive renal insufficiency

AKI:

Acute kidney injury

UTI:

Urinary tract infection

SSI:

Surgical site infection

PJI:

Periprosthetic joint infection

SMD:

Standardized mean difference

OR:

Odds ratio

CI:

Confidence interval

References

  1. Kurtz, S., Ong, K., Lau, E., Mowat, F., & Halpern, M. (2007). Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. Journal of Bone and Joint Surgery. American Volume, 89, 780–785. https://doi.org/10.2106/JBJS.F.00222

    Article  Google Scholar 

  2. Liu, S. S., Della Valle, A. G., Besculides, M. C., Gaber, L. K., & Memtsoudis, S. G. (2009). Trends in mortality, complications, and demographics for primary hip arthroplasty in the United States. International Orthopaedics, 33, 643–651. https://doi.org/10.1007/s00264-008-0549-4

    Article  Google Scholar 

  3. Memtsoudis, S. G., Della Valle, A. G., Besculides, M. C., Gaber, L., & Laskin, R. (2009). Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty. Journal of Arthroplasty, 24, 518–527. https://doi.org/10.1016/j.arth.2008.01.307

    Article  Google Scholar 

  4. Kim, C. W., Kim, H. J., Lee, C. R., Wang, L., & Rhee, S. J. (2020). Effect of chronic kidney disease on outcomes of total joint arthroplasty: A meta-analysis. Knee Surg Relat Res, 32, 12. https://doi.org/10.1186/s43019-020-0029-8

    Article  Google Scholar 

  5. Kulshrestha, V., Sood, M., Kumar, S., Sood, N., Kumar, P., & Padhi, P. (2021). Does risk mitigation reduce ninety-day complications in patients undergoing total knee arthroplasty? A cohort study. Clin Orthop Surg, 13, e70.

    Google Scholar 

  6. Park, B. Y., Lim, K. P., Shon, W. Y., Shetty, Y. N., & Heo, K. S. (2019). Comparison of functional outcomes and associated complications in patients who underwent total hip arthroplasty for femoral neck fracture in relation to their underlying medical comorbidities. Hip Pelvis, 31, 232–237. https://doi.org/10.5371/hp.2019.31.4.232

    Article  Google Scholar 

  7. Podmore, B., Hutchings, A., van der Meulen, J., Aggarwal, A., & Konan, S. (2018). Impact of comorbid conditions on outcomes of hip and knee replacement surgery: A systematic review and meta-analysis. British Medical Journal Open, 8, e021784. https://doi.org/10.1136/bmjopen-2018-021784

    Article  Google Scholar 

  8. Vogelmeier, C. F., Criner, G. J., Martinez, F. J., Anzueto, A., Barnes, P. J., Bourbeau, J., et al. (2017). Global strategy for the diagnosis, management and prevention of chronic obstructive lung disease 2017 report: GOLD executive summary. Respirology, 22, 575–601. https://doi.org/10.1111/resp.13012

    Article  Google Scholar 

  9. Quaderi, S. A., & Hurst, J. R. (2018). The unmet global burden of COPD. Glob Health Epidemiol Genom, 3, e4. https://doi.org/10.1017/gheg.2018.1

    Article  CAS  Google Scholar 

  10. Rycroft, C. E., Heyes, A., Lanza, L., & Becker, K. (2012). Epidemiology of chronic obstructive pulmonary disease: A literature review. International Journal of Chronic Obstructive Pulmonary Disease, 7, 457–494. https://doi.org/10.2147/COPD.S32330

    Article  Google Scholar 

  11. Gu, A., Wu, S., Mancino, F., Liu, J., Ast, M. P., Abdel, M. P., et al. (2018). Impact of chronic obstructive pulmonary disease on postoperative complications following simultaneous bilateral total knee arthroplasty. The Journal of Knee Surgery, 34, 322–327. https://doi.org/10.1055/s-0039-1695766

    Article  Google Scholar 

  12. Liao, K. M., & Lu, H. Y. (2016). Complications after total knee replacement in patients with chronic obstructive pulmonary disease: A nationwide case-control study. Medicine (Baltimore), 95, e4835. https://doi.org/10.1097/MD.0000000000004835

    Article  Google Scholar 

  13. Liao, K. M., & Lu, H. Y. (2016). A national analysis of complications following total hip replacement in patients with chronic obstructive pulmonary disease. Medicine (Baltimore), 95, e3182. https://doi.org/10.1097/MD.0000000000003182

    Article  CAS  Google Scholar 

  14. Vakharia, R. M., Adams, C. T., Anoushiravani, A. A., Ehiorobo, J. O., Mont, M. A., & Roche, M. W. (2020). Chronic obstructive pulmonary disease is associated with higher rates of venous thromboemboli following primary total knee arthroplasty. Journal of Arthroplasty, 35(2066–2071), e9. https://doi.org/10.1016/j.arth.2020.03.053

    Article  Google Scholar 

  15. Yakubek, G. A., Curtis, G. L., Khlopas, A., Faour, M., Klika, A. K., Mont, M. A., et al. (2018). Chronic obstructive pulmonary disease is associated with short-term complications following total knee arthroplasty. Journal of Arthroplasty, 33, 2623–2626. https://doi.org/10.1016/j.arth.2018.03.011

    Article  Google Scholar 

  16. Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ, 339, b2535. https://doi.org/10.1136/bmj.b2535

    Article  Google Scholar 

  17. Hayden, J. A., van der Windt, D. A., Cartwright, J. L., Côté, P., & Bombardier, C. (2013). Assessing bias in studies of prognostic factors. Annals of Internal Medicine, 158, 280–286. https://doi.org/10.7326/0003-4819-158-4-201302190-00009

    Article  Google Scholar 

  18. Iorio, A., Spencer, F. A., Falavigna, M., Alba, C., Lang, E., Burnand, B., et al. (2015). Use of GRADE for assessment of evidence about prognosis: Rating confidence in estimates of event rates in broad categories of patients. BMJ, 350, h870.

    Article  Google Scholar 

  19. Guyatt, G. H., Oxman, A. D., Vist, G. E., Kunz, R., Falck-Ytter, Y., Alonso-Coello, P., et al. (2008). GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 336, 924–926.

    Article  Google Scholar 

  20. Cumpston, M., Li, T., Page, M. J., Chandler, J., Welch, V. A., Higgins, J. P., et al. (2019). Updated guidance for trusted systematic reviews: a new edition of the cochrane handbook for systematic reviews of interventions. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.ED000142

    Article  Google Scholar 

  21. Egger, M., Davey Smith, G., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315, 629–634. https://doi.org/10.1136/bmj.315.7109.629

    Article  CAS  Google Scholar 

  22. Klasan, A., Dworschak, P., Heyse, T. J., Ruchholtz, S., Alter, P., Vogelmeier, C. F., et al. (2018). COPD as a risk factor of the complications in lower limb arthroplasty: A patient-matched study. International Journal of Chronic Obstructive Pulmonary Disease, 13, 2495–2499. https://doi.org/10.2147/COPD.S161577

    Article  Google Scholar 

  23. Lemme, N. J., Glasser, J. L., Yang, D. S., Testa, E. J., Daniels, A. H., & Antoci, V. (2021). Chronic obstructive pulmonary disease associated with prolonged opiate use, increased short-term complications, and the need for revision surgery following total knee arthroplasty. The Journal of Knee Surgery. https://doi.org/10.1055/s-0041-1733883

    Article  Google Scholar 

  24. Yakubek, G. A., Curtis, G. L., Sodhi, N., Faour, M., Klika, A. K., Mont, M. A., et al. (2018). Chronic obstructive pulmonary disease is associated with short-term complications following total hip arthroplasty. Journal of Arthroplasty, 33, 1926–1929. https://doi.org/10.1016/j.arth.2017.12.043

    Article  Google Scholar 

  25. Yang, D. S., Glasser, J., Lemme, N. J., Quinn, M., Daniels, A. H., & Antoci, V., Jr. (2021). Increased medical and implant-related complications in total hip arthroplasty patients with underlying chronic obstructive pulmonary disease. The Journal of Arthroplasty. https://doi.org/10.1016/j.arth.2021.02.011

    Article  Google Scholar 

  26. Gan, W. Q., Man, S. F., Senthilselvan, A., & Sin, D. D. (2004). Association between chronic obstructive pulmonary disease and systemic inflammation: A systematic review and a meta-analysis. Thorax, 59, 574–580. https://doi.org/10.1136/thx.2003.019588

    Article  CAS  Google Scholar 

  27. Thomsen, M., Dahl, M., Lange, P., Vestbo, J., & Nordestgaard, B. G. (2012). Inflammatory biomarkers and comorbidities in chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 186(10), 982–988. https://doi.org/10.1164/rccm.201206-1113OC

    Article  CAS  Google Scholar 

  28. Gupta, H., Ramanan, B., Gupta, P. K., Fang, X., Polich, A., Modrykamien, A., et al. (2013). Impact of COPD on postoperative outcomes: Results from a national database. Chest, 143, 1599–1606. https://doi.org/10.1378/chest.12-1499

    Article  Google Scholar 

  29. Barnes, P. J., & Celli, B. R. (2009). Systemic manifestations and comorbidities of COPD. European Respiratory Journal, 33, 1165–1185. https://doi.org/10.1183/09031936.00128008

    Article  CAS  Google Scholar 

  30. Corsonello, A., Antonelli Incalzi, R., Pistelli, R., Pedone, C., Bustacchini, S., & Lattanzio, F. (2011). Comorbidities of chronic obstructive pulmonary disease. Current Opinion in Pulmonary Medicine, 17(Suppl 1), S21–S28. https://doi.org/10.1097/01.mcp.0000410744.75216.d0

    Article  Google Scholar 

  31. Bertges, D. J., Goodney, P. P., Zhao, Y., Schanzer, A., Nolan, B. W., Likosky, D. S., et al. (2010). The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the revised cardiac risk index in vascular surgery patients. Journal of Vascular Surgery, 52, 674–683. https://doi.org/10.1016/j.jvs.2010.03.031

    Article  Google Scholar 

  32. Gunen, H., Gulbas, G., In, E., Yetkin, O., & Hacievliyagil, S. S. (2010). Venous thromboemboli and exacerbations of COPD. European Respiratory Journal, 35, 1243–1248. https://doi.org/10.1183/09031936.00120909

    Article  CAS  Google Scholar 

  33. Stein, P. D., Beemath, A., Meyers, F. A., & Olson, R. E. (2007). Pulmonary embolism and deep venous thrombosis in hospitalized adults with chronic obstructive pulmonary disease. Journal of Cardiovascular Medicine (Hagerstown, Md.), 8, 253–257. https://doi.org/10.2459/01.JCM.0000263509.35573.2c

    Article  Google Scholar 

  34. Donaldson, G. C., Hurst, J. R., Smith, C. J., Hubbard, R. B., & Wedzicha, J. A. (2010). Increased risk of myocardial infarction and stroke following exacerbation of COPD. Chest, 37, 1091–1097.

    Article  Google Scholar 

  35. Rothnie, K. J., Yan, R., Smeeth, L., Smeeth, L., & Quint, J. K. (2015). Risk of myocardial infarction (MI) and death following MI in people with chronic obstructive pulmonary disease (COPD): A systematic review and meta-analysis. British Medical Journal Open, 5, e007824.

    Google Scholar 

  36. Smetana, G. W., Lawrence, V. A., Cornell, J. E., College, A., & of Physcians,. (2006). Preoperative pulmonary risk stratification for noncardiothoracic surgery: Systematic review for the American College of Physicians. Annals of Internal Medicine, 144, 581–595. https://doi.org/10.7326/0003-4819-144-8-200604180-00009

    Article  Google Scholar 

  37. van Lier, F., van der Geest, P. J., Hoeks, S. E., van Gestel, Y. R., Hol, J. W., Sin, D. D., et al. (2011). Epidural analgesia is associated with improved health outcomes of surgical patients with chronic obstructive pulmonary disease. Anesthesiology, 115, 315–321. https://doi.org/10.1097/ALN.0b013e318224cc5c

    Article  CAS  Google Scholar 

  38. Hausman, M. S., Jr., Jewell, E. S., & Engoren, M. (2015). Regional versus general anesthesia in surgical patients with chronic obstructive pulmonary disease: Does avoiding general anesthesia reduce the risk of postoperative complications? Anesthesia and Analgesia, 120, 1405–1412. https://doi.org/10.1213/ANE.0000000000000574

    Article  CAS  Google Scholar 

  39. Rodrigues, A. J., Evora, P. R., Bassetto, S., Alves Júnior, L., Scorzoni Filho, A., Araujo, W. F., et al. (2009). Risk factors for acute renal failure after heart surgery. Revista Brasileira de Cirurgia Cardiovascular, 24, 441–446. https://doi.org/10.1590/s0102-76382009000500003

    Article  Google Scholar 

  40. Chen, J., Zhang, F., Liu, C. Y., Yuan, Q. M., Di, X. S., Long, S. W., et al. (2020). Impact of chronic kidney disease on outcomes after total joint arthroplasty: A meta-analysis and systematic review. International Orthopaedics, 44, 215–229. https://doi.org/10.1007/s00264-019-04437-4

    Article  Google Scholar 

  41. Incalzi, R. A., Corsonello, A., Pedone, C., Battaglia, S., Paglino, G., Bellia, V., et al. (2010). Chronic renal failure: A neglected comorbidity of COPD. Chest, 137, 831–837. https://doi.org/10.1378/chest.09-1710

    Article  Google Scholar 

  42. Qin, W., Huang, X., Yang, H., & Shen, M. (2020). The influence of diabetes mellitus on patients undergoing primary total lower extremity arthroplasty: A systematic review and meta-analysis. BioMed Research International, 2020, 6661691. https://doi.org/10.1155/2020/6661691

    Article  Google Scholar 

  43. Bhat, T. A., Panzica, L., Kalathil, S. G., & Thanavala, Y. (2015). Immune dysfunction in patients with chronic obstructive pulmonary disease. Annals of the American Thoracic Society, 12(Suppl 2), S169–S175. https://doi.org/10.1513/AnnalsATS.201503-126AW

    Article  Google Scholar 

  44. Shin, K. H., Han, S. B., & Song, J. E. (2022). Risk of periprosthetic joint infection in patients with total knee arthroplasty undergoing colonoscopy: A nationwide propensity score matched study. Journal of Arthroplasty, 37, 49–56. https://doi.org/10.1016/j.arth.2021.09.015

    Article  Google Scholar 

  45. Guo, S., & Dipietro, L. A. (2010). Factors affecting wound healing. Journal of Dental Research, 89, 219–229. https://doi.org/10.1177/0022034509359125

    Article  CAS  Google Scholar 

  46. Perotin, J. M., Adam, D., Vella-Boucaud, J., Delepine, G., Sandu, S., Jonvel, A. C., et al. (2014). Delay of airway epithelial wound repair in COPD is associated with airflow obstruction severity. Respiratory Research, 15, 151. https://doi.org/10.1186/s12931-014-0151-9

    Article  Google Scholar 

  47. Kunutsor, S. K., Whitehouse, M. R., Blom, A. W., Beswick, A. D., INFORM Team. (2016). Patient-related risk factors for periprosthetic joint infection after total joint arthroplasty: a systematic review and meta-analysis. PLoS One, 11, e0150866. https://doi.org/10.1371/journal.pone.0150866

    Article  CAS  Google Scholar 

  48. Bohl, D. D., Sershon, R. A., Fillingham, Y. A., & Della Valle, C. J. (2016). Incidence, risk factors, and sources of sepsis following total joint arthroplasty. Journal of Arthroplasty, 31, 2875-2879.e2. https://doi.org/10.1016/j.arth.2016.05.031

    Article  Google Scholar 

  49. Gupta, P. K., Mactaggart, J. N., Natarajan, B., Lynch, T. G., Arya, S., Gupta, H., et al. (2012). Predictive factors for mortality after open repair of paravisceral abdominal aortic aneurysm. Journal of Vascular Surgery, 55, 666–673. https://doi.org/10.1016/j.jvs.2011.09.078

    Article  Google Scholar 

  50. Saleh, H. Z., Mohan, K., Shaw, M., Al-Rawi, O., Elsayed, H., Walshaw, M., et al. (2012). Impact of chronic obstructive pulmonary disease severity on surgical outcomes in patients undergoing non-emergent coronary artery bypass grafting. European Journal of Cardio-Thoracic Surgery, 42, 108–113. https://doi.org/10.1093/ejcts/ezr271

    Article  Google Scholar 

  51. Devereaux, P. J., Goldman, L., Cook, D. J., Gilbert, K., Leslie, K., & Guyatt, G. H. (2005). Perioperative cardiac events in patients undergoing noncardiac surgery: A review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ, 173, 627–634. https://doi.org/10.1503/cmaj.050011

    Article  CAS  Google Scholar 

  52. Temgoua, M. N., Tochie, J. N., Noubiap, J. J., Agbor, V. N., Danwang, C., Endomba, F. T. A., et al. (2017). Global incidence and case fatality rate of pulmonary embolism following major surgery: A protocol for a systematic review and meta-analysis of cohort studies. Systematic Reviews, 6(1), 240. https://doi.org/10.1186/s13643-017-0647-8

    Article  Google Scholar 

  53. Sabeh, K. G., Rosas, S., Buller, L. T., Freiberg, A. A., Emory, C. L., & Roche, M. W. (2019). The impact of medical comorbidities on primary total knee arthroplasty reimbursements. The Journal of Knee Surgery, 32, 475–482. https://doi.org/10.1055/s-0038-1651529

    Article  Google Scholar 

  54. Manganas, H., Lacasse, Y., Bourgeois, S., Perron, J., Dagenais, F., & Maltais, F. (2007). Postoperative outcome after coronary artery bypass grafting in chronic obstructive pulmonary disease. Canadian Respiratory Journal, 14, 19–24. https://doi.org/10.1155/2007/378963

    Article  Google Scholar 

  55. Prokopetz, J. J., Losina, E., Bliss, R. L., Wright, J., Baron, J. A., & Katz, J. N. (2012). Risk factors for revision of primary total hip arthroplasty: A systematic review. BMC Musculoskeletal Disorders, 13, 251. https://doi.org/10.1186/1471-2474-13-251

    Article  Google Scholar 

  56. Jasper, L. L., Jones, C. A., Mollins, J., Pohar, S. L., & Beaupre, L. A. (2016). Risk factors for revision of total knee arthroplasty: A scoping review. BMC Musculoskeletal Disorders, 17, 182. https://doi.org/10.1186/s12891-016-1025-8

    Article  CAS  Google Scholar 

  57. Licker, M., Schweizer, A., Ellenberger, C., Tschopp, J. M., Diaper, J., & Clergue, F. (2007). Perioperative medical management of patients with COPD. International Journal of Chronic Obstructive Pulmonary Disease, 2, 493–515.

    Google Scholar 

  58. Kulshrestha, V., Sood, M., Kumar, S., Sood, N., Kumar, P., & Padhi, P. P. (2022). Does risk mitigation reduce 90-day complications in patients undergoing total knee arthroplasty?: A cohort study. Clinics in Orthopedic Surgery, 14, 56–68.

    Article  Google Scholar 

  59. Kimm, H., Yun, J. E., Lee, S. H., Jang, Y., & Jee, S. H. (2012). Validity of the diagnosis of acute myocardial infarction in korean national medical health insurance claims data: The korean heart study (1). Korean Circulation Journal, 42, 10–15. https://doi.org/10.4070/kcj.2012.42.1.10

    Article  Google Scholar 

Download references

Funding

No funding source was applicable to any part of this study.

Author information

Authors and Affiliations

  1. Department of Orthopedic Surgery, Incheon Nanoori Hospital, 156 Janje-ro, Bupyeong-gu, 21353, Incheon, South Korea

    Kyun-Ho Shin & Jin-Uk Kim

  2. Department of Neurosurgery, Gangnam Nanoori Hospital, Seoul, South Korea

    Il-Tae Jang

  3. Department of Orthopedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul, South Korea

    Seung-Beom Han

  4. Joint Center, Inbone Hospital, Paju-si, Gyeonggi-do, South Korea

    Sang-Bum Kim

Authors
  1. Kyun-Ho Shin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jin-Uk Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Il-Tae Jang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Seung-Beom Han
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sang-Bum Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

KHS was the project leader and participated in all aspects of the study, including planning, design, literature searches, data screening and extraction, quality appraisal, and management of all aspects of manuscript preparation and submission. JUK, ITJ, SBH, and SBK contributed to literature searches, data screening and extraction, quality appraisal, and manuscript editing. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Kyun-Ho Shin.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shin, KH., Kim, JU., Jang, IT. et al. Impact of Chronic Obstructive Pulmonary Disease on Outcomes After Total Joint Arthroplasty: A Meta-analysis and Systematic Review. JOIO 57, 211–226 (2023). https://doi.org/10.1007/s43465-022-00794-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s43465-022-00794-2

Keywords

Search

Navigation