International Orthopaedics

, 33:1739 | Cite as

Risk factors for pulmonary embolism after hip and knee arthroplasty: a population-based study

  • Stavros G. Memtsoudis
  • Melanie C. Besculides
  • Licia Gaber
  • Spencer Liu
  • Alejandro González Della Valle
Original Paper


Pulmonary embolism (PE) is a cause of death after total hip and knee arthroplasty (THA, TKA). We characterised the patient population suffering from in-hospital PE and identified perioperative risk factors associated with PE using nationally representative data. Data from the National Hospital Discharge Survey between 1990 and 2004 on patients who underwent primary or revision THA/TKA in the United States were analysed. Multivariate regression analysis was performed to determine if perioperative factors were associated with increased risk of in-hospital PE. An estimated 6,901,324 procedures were identified. The incidence of in-hospital PE was 0.36%. Factors associated with an increased risk for the diagnosis of PE included: revision THA, female gender, dementia, obesity, renal and cerebrovascular disease. An increased association with PE was found among patients with diagnosis of Adult Respiratory Distress Syndrome (ARDS), psychosis (confusion), and peripheral thrombotic events. Our findings may be useful in stratifying the individual patient’s risk of PE after surgery.


L’embolie pulmonaire (PE) est une cause de décès après prothèse totale de hanche ou du genou (THA, TKA). Nous avons essayé de déterminer quelle population pouvait présenter une telle complication et identifier les facteurs de risques pré-opératoires. Pour cela, nous avons analysé nos données hospitalières nationales entre 1990 et 2004 sur tous les patients ayant bénéficié d’une prothèse de hanche ou du genou primaire ou de révision aux Etats-Unis. Une analyse statistique a été réalisée afin de déterminer quels sont les facteurs de risque péri-opératoires associés. 6 901 324 procédures ont été identifiées. Le pourcentage d’embolie pulmonaire durant l’hospitalisation a été de 0,36%. Les facteurs associés sont la révision prothétique, le sexe féminin, la démence, l’obésité, les problèmes rénaux et les problèmes cérébraux vasculaires. Le taux le plus élevé d’embolie pulmonaire a été également trouvé chez les patients ayant un diagnostic d’ARDS et de troubles confusionnels ainsi que d’évènements thrombotiques périphériques. Ces données peuvent être utiles pour évaluer le risque d’embolie pulmonaire chez les patients après chirurgie arthroplastique.



  1. 1.
    Barba R, Zapatero A, Losa JE, Valdes V, Todoli JA, Di Micco P, Monreal M (2008) Body mass index and mortality in patients with acute venous thromboembolism: findings from the RIETE registry. J Thromb Haemost 6:595–600CrossRefPubMedGoogle Scholar
  2. 2.
    Beksac B, Gonzalez Della Valle A, Anderson J, Sharrock NE, Sculco TP, Salvati EA (2007) Symptomatic thromboembolism after one-stage bilateral THA with a multimodal prophylaxis protocol. Clin Orthop Relat Res 463:114–119PubMedGoogle Scholar
  3. 3.
    Beksac B, Gonzalez Della Valle A, Salvati EA (2006) Thromboembolic disease after total hip arthroplasty: who is at risk? Clin Orthop Relat Res 453:211–224CrossRefPubMedGoogle Scholar
  4. 4.
    Bhattacharyya T, Iorio R, Healy WL (2002) Rate of and risk factors for acute inpatient mortality after orthopaedic surgery. J Bone Joint Surg Am 84-A:562–572PubMedGoogle Scholar
  5. 5.
    Burnett RS, Clohisy JC, Wright RW, McDonald DJ, Shively RA, Givens SA, Barrack RL (2007) Failure of the American College of Chest Physicians-1A protocol for lovenox in clinical outcomes for thromboembolic prophylaxis. J Arthroplasty 22:317–324CrossRefPubMedGoogle Scholar
  6. 6.
    Butt AJ, McCarthy T, Kelly IP, Glynn T, McCoy G (2005) Sciatic nerve palsy secondary to postoperative haematoma in primary total hip replacement. J Bone Joint Surg Br 87-B:1465–1467CrossRefGoogle Scholar
  7. 7.
    Gangireddy C, Rectenwald JR, Upchurch GR, Wakefield TW, Khuri S, Henderson WG, Henke PK (2007) Risk factors and clinical impact of postoperative symptomatic venous thromboembolism. J Vasc Surg 45:335–341CrossRefPubMedGoogle Scholar
  8. 8.
    Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG (2004) Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 126:338S–400SCrossRefPubMedGoogle Scholar
  9. 9.
    Iezzoni LI, Foley SM, Daley J, Hughes J, Fisher ES, Heeren T (1992) Comorbidities, complications, and coding bias. Does the number of diagnosis codes matter in predicting in-hospital mortality? JAMA 267:2197–2203CrossRefPubMedGoogle Scholar
  10. 10.
    Keenan CR, White RH (2007) The effects of race/ethnicity and sex on the risk of venous thromboembolism. Curr Opin Pulm Med 13:377–383PubMedGoogle Scholar
  11. 11.
    Keene J, Hope T, Fairburn CG, Jacoby R (2001) Death and dementia. Int J Geriatr Psychiatry 16:969–974CrossRefPubMedGoogle Scholar
  12. 12.
    Lowe GD, Haverkate F, Thompson SG, Turner RM, Bertina RM, Turpie AG, Mannucci PM (1999) Prediction of deep vein thrombosis after elective hip replacement surgery by preoperative clinical and haemostatic variables: the ECAT DVT study. European Concerted Action on Thrombosis. Thromb Haemost 81:879–886PubMedGoogle Scholar
  13. 13.
    Mahomed NN, Barrett J, Katz JN, Baron JA, Wright J, Losina E (2005) Epidemiology of total knee replacement in the United States Medicare population. J Bone Joint Surg Am 87:1222–1228CrossRefPubMedGoogle Scholar
  14. 14.
    Mantilla CB, Horlocker TT, Schroeder DR, Berry DJ, Brown DL (2003) Risk factors for clinically relevant pulmonary embolism and deep venous thrombosis in patients undergoing primary hip or knee arthroplasty. Anesthesiology 99:552–560CrossRefPubMedGoogle Scholar
  15. 15.
    Memtsoudis SG, Gonzalez Della Valle A, Besculides MC, Garber LK, Laskin RS (2008) Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty. 3,830,420 hospital discharges in the Unites States between 1990 and 2004. J Arthroplasty (in press)Google Scholar
  16. 16.
    Memtsoudis SG, Gonzalez Della Valle A, Besculides MC, Garber LK, Sculco TP (2008) In-hospital complications and mortality of patients undergoing primary unilateral, bilateral and revision total knee arthroplasty. A study of 4,169,489 hospital discharges in the United States between 1990 and 2004. Clin Orthop (in press)Google Scholar
  17. 17.
    Monreal M, Falga C, Valle R, Barba R, Bosco J, Beato JL, Maestre A (2006) Venous thromboembolism in patients with renal insufficiency: findings from the RIETE Registry. Am J Med 119:1073–1079CrossRefPubMedGoogle Scholar
  18. 18.
    Mont MA, Jones LC, Rajadhyaksha AD, Shuler MS, Hungerford DS, Sieve-Smith L, Wang P, Cordista AG, Glueck CJ (2004) Risk factors for pulmonary emboli after total hip or knee arthroplasty. Clin Orthop 422:154–163CrossRefPubMedGoogle Scholar
  19. 19.
    Parvizi J, Sullivan TA, Trousdale RT, Lewallen DG (2001) Thirty-day mortality after total knee arthroplasty. J Bone Joint Surg Am 83-A:1157–1161PubMedGoogle Scholar
  20. 20.
    Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE (2007) Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am 89:33–38CrossRefPubMedGoogle Scholar
  21. 21.
    American Academy of Orthopaedic Surgeons (2007) Prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. Accessed September 2008
  22. 22.
    Ridker RM, Miletich JP, Hennekens CH, Buring JE (1997) Ethnic distribution of factor V Leiden in 4047 men and women. Implications for venous thromboembolism screening. JAMA 277:1305–1307CrossRefPubMedGoogle Scholar
  23. 23.
    Sanchez-Ballester J, Smith M, Hassan K, Kershaw S, Elsworth CS, Jacobs L (2005) Wound infection in the management of hip fractures: a comparison between low-molecular weight heparin and mechanical prophylaxis. Acta Orthop Belg 71:55–59PubMedGoogle Scholar
  24. 24.
    Centers for Disease Control and Prevention (2007) Selected articles using National Hospital Discharge Survey or National Survey of Ambulatory Surgery data. Accessed September 2008
  25. 25.
    Sharrock NE, Gonzalez Della Valle A, Go G, Lyman S, Salvati EA (2008) Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty. Clin Orthop Relat Res 466:714–721CrossRefPubMedGoogle Scholar
  26. 26.
    Sharrock NE, Gonzalez Della Valle A, Go G, Lyman S, Salvati EA (2008) Reply to letter to editor: potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty. Clin Orthop Relat Res 466(8)Google Scholar
  27. 27.
    Stein PD, Beemath A, Meyers FA, Olson RE (2007) Pulmonary embolism and deep venous thrombosis in hospitalized adults with chronic obstructive pulmonary disease. J Cardiovasc Med (Hagerstown) 8:253–257Google Scholar
  28. 28.
    Warwick D, Dahl OE, Fisher WD (2008) Orthopaedic thromboprophylaxis: limitations of current guidelines. J Bone Joint Surg Br 90:127–132CrossRefPubMedGoogle Scholar
  29. 29.
    White RH, Dager WE, Zhou H, Murin S (2006) Racial and gender differences in the incidence of recurrent venous thromboembolism. Thromb Haemost 96:267–273PubMedGoogle Scholar
  30. 30.
    White RH, Gettner S, Newman JM, Trauner KB, Romano PS (2000) Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty. N Engl J Med 343:1758–1764CrossRefPubMedGoogle Scholar
  31. 31.
    White RH, Henderson MC (2002) Risk factors for venous thromboembolism after total hip and knee replacement surgery. Curr Opin Pulm Med 8:365–371CrossRefPubMedGoogle Scholar
  32. 32.
    White RH, Zhou H, Romano PS (1998) Incidence of idiopathic deep venous thrombosis and secondary thromboembolism among ethnic groups in California. Ann Intern Med 128:737–740PubMedGoogle Scholar
  33. 33.
    Zhan C, Kaczmarek R, Loyo-Berrios N, Sangl J, Bright RA (2007) Incidence and short-term outcomes of primary and revision hip replacement in the United States. J Bone Joint Surg Am 89:526–533CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Stavros G. Memtsoudis
    • 1
  • Melanie C. Besculides
    • 1
  • Licia Gaber
    • 3
  • Spencer Liu
    • 1
  • Alejandro González Della Valle
    • 2
  1. 1.Department of AnesthesiologyHospital for Special Surgery, Weill Medical College of Cornell UniversityNew YorkUSA
  2. 2.Department of Orthopaedic SurgeryHospital for Special Surgery, Weill Medical College of Cornell UniversityNew YorkUSA
  3. 3.LKG ConsultingPlainsboroUSA

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