International Orthopaedics

, Volume 39, Issue 4, pp 777–786 | Cite as

A nationwide analysis of risk factors for in-hospital myocardial infarction after total joint arthroplasty

  • Mariano E. MenendezEmail author
  • Stavros G. Memtsoudis
  • Marion Opperer
  • Friedrich Boettner
  • Alejandro Gonzalez Della Valle
Original Paper



Despite acute myocardial infarction (AMI) being a feared medical complication and currently a major cause of death after total hip and knee arthroplasty (THA/TKA), little is known about its peri-operative associated factors.


Data for this retrospective cohort study were extracted from the Nationwide Inpatient Sample for 2008–2011. Multivariate logistic regression modeling was performed to determine peri-operative factors associated with the development of inpatient AMI following THA/TKA.


An estimated 3,096,791 procedures were identified. Perioperative AMI rates were 0.25 % for THA and 0.18 % for TKA. Patients with AMI had significantly greater comorbidity burden, higher peri-operative mortality rates, longer length of hospital stay and increased complication rates. Independent risk factors for the development of AMI comprised advance age, male gender [odds ratio (OR) 1.4, 95 % confidence interval (CI) 1.4–1.5], THA surgery (OR 1.3, 95 % CI 1.3–1.4), low household income (OR 1.3, 95 % CI 1.2–1.4), history of cardiac disease (coronary artery disease: OR 4.9, 95 % CI 4.6–5.2; congestive heart failure: OR 2.6, 95 % CI 2.4–2.8; valvular disease: OR 1.2, 95 % CI 1.1–1.3), diabetes (OR 1.1, 95 % CI 1.1–1.2), pulmonary circulation disorders (OR 1.4, 95 % CI 1.2–1.6), cerebrovascular disease (OR 2.3, 95 % CI 2.0–2.6), peripheral vascular disorders (OR 1.5, 95 % CI 1.4–1.7), coagulopathy (OR 1.4, 95 % CI 1.2–1.5), AIDS/HIV infection (OR 7.9, 95 % CI 4.5–13.9), deficiency anaemia (OR 1.4, 95 % CI 1.3–1.5), fluid and electrolyte disorders (OR 1.9, 95 % CI 1.8–2.0) and the occurrence of concomitant postoperative complications.


Our findings can be used to better identify patients at high risk of AMI and to develop strategies aimed at diminishing its incidence, which could in turn translate to improved hospital efficiency and quality of care.


Myocardial infarction Knee arthroplasty Hip arthroplasty Risk factors Epidemiology 



This study was partially funded by the generous donation of Mr. Glenn Bergenfield and the Sidney Milton and Leoma Simon Foundation.

Conflicts of interest



  1. 1.
    Kirksey M, Chiu YL, Ma Y, Della Valle AG, Poultsides L, Gerner P, Memtsoudis SG (2012) Trends in in-hospital major morbidity and mortality after total joint arthroplasty: United States 1998–2008. Anesth Analg 115(2):321–327. doi: 10.1213/ANE.0b013e31825b6824 CrossRefPubMedGoogle Scholar
  2. 2.
    Parvizi J, Johnson BG, Rowland C, Ereth MH, Lewallen DG (2001) Thirty-day mortality after elective total hip arthroplasty. J Bone Joint Surg Am 83-A(10):1524–1528PubMedGoogle Scholar
  3. 3.
    Parvizi J, Sullivan TA, Trousdale RT, Lewallen DG (2001) Thirty-day mortality after total knee arthroplasty. J Bone Joint Surg Am 83-A(8):1157–1161PubMedGoogle Scholar
  4. 4.
    Poultsides LA, Gonzalez Della Valle A, Memtsoudis SG, Ma Y, Roberts T, Sharrock N, Salvati E (2012) Meta-analysis of cause of death following total joint replacement using different thromboprophylaxis regimens. J Bone Joint Surg (Br) 94(1):113–121. doi: 10.1302/0301-620X.94B1.27301 CrossRefGoogle Scholar
  5. 5.
    Mantilla CB, Horlocker TT, Schroeder DR, Berry DJ, Brown DL (2002) Frequency of myocardial infarction, pulmonary embolism, deep venous thrombosis, and death following primary hip or knee arthroplasty. Anesthesiology 96(5):1140–1146CrossRefPubMedGoogle Scholar
  6. 6.
    Pulido L, Parvizi J, Macgibeny M, Sharkey PF, Purtill JJ, Rothman RH, Hozack WJ (2008) In hospital complications after total joint arthroplasty. J Arthroplasty 23(6 Suppl 1):139–145. doi: 10.1016/j.arth.2008.05.011 CrossRefPubMedGoogle Scholar
  7. 7.
    Parry MC, Smith AJ, Blom AW (2011) Early death following primary total knee arthroplasty. J Bone Joint Surg Am 93(10):948–953. doi: 10.2106/JBJS.J.00425 CrossRefPubMedGoogle Scholar
  8. 8.
    D’Apuzzo MR, Pao AW, Novicoff WM, Browne JA (2014) Age as an independent risk factor for postoperative morbidity and mortality after total joint arthroplasty in patients 90 years of age or older. J Arthroplasty 29(3):477–480. doi: 10.1016/j.arth.2013.07.045 CrossRefPubMedGoogle Scholar
  9. 9.
    Basilico FC, Sweeney G, Losina E, Gaydos J, Skoniecki D, Wright EA, Katz JN (2008) Risk factors for cardiovascular complications following total joint replacement surgery. Arthritis Rheum 58(7):1915–1920. doi: 10.1002/art.23607 CrossRefPubMedCentralPubMedGoogle Scholar
  10. 10.
    Gandhi R, Petruccelli D, Devereaux PJ, Adili A, Hubmann M, de Beer J (2006) Incidence and timing of myocardial infarction after total joint arthroplasty. J Arthroplasty 21(6):874–877. doi: 10.1016/j.arth.2005.10.007 CrossRefPubMedGoogle Scholar
  11. 11.
    Singh JA, Jensen MR, Harmsen WS, Gabriel SE, Lewallen DG (2011) Cardiac and thromboembolic complications and mortality in patients undergoing total hip and total knee arthroplasty. Ann Rheum Dis 70(12):2082–2088. doi: 10.1136/ard.2010.148726 CrossRefPubMedCentralPubMedGoogle Scholar
  12. 12.
    Gonzalez Della Valle A, Chiu YL, Ma Y, Mazumdar M, Memtsoudis SG (2012) The metabolic syndrome in patients undergoing knee and hip arthroplasty: trends and in-hospital outcomes in the United States. J Arthroplasty 27(10):1743–1749 e1741. doi: 10.1016/j.arth.2012.04.011 CrossRefPubMedGoogle Scholar
  13. 13.
    Memtsoudis SG, Bombardieri AM, Ma Y, Walz JM, Chiu YL, Mazumdar M (2012) Mortality of patients with respiratory insufficiency and adult respiratory distress syndrome after surgery: the obesity paradox. J Intensive Care Med 27(5):306–311. doi: 10.1177/0885066611411410 CrossRefPubMedGoogle Scholar
  14. 14.
    Memtsoudis SG, Dy CJ, Ma Y, Chiu YL, Gonzalez Della Valle A, Mazumdar M (2012) In-hospital patient falls after total joint arthroplasty: incidence, demographics, and risk factors in the United States. J Arthroplasty 27(6):823–828 e821. doi: 10.1016/j.arth.2011.10.010 CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Memtsoudis SG, Pumberger M, Ma Y, Chiu YL, Fritsch G, Gerner P, Poultsides L, Gonzalez Della Valle A, (2012) Epidemiology and risk factors for perioperative mortality after total hip and knee arthroplasty. J Orthop Res 30(11):1811–1821. doi: 10.1002/jor.22139 CrossRefPubMedCentralPubMedGoogle Scholar
  16. 16.
    Browne JA, Sandberg BF, D’Apuzzo MR, Novicoff WM (2014) Depression is associated with early postoperative outcomes following total joint arthroplasty: a nationwide database study. J Arthroplasty 29(3):481–483. doi: 10.1016/j.arth.2013.08.025 CrossRefPubMedGoogle Scholar
  17. 17.
    D’Apuzzo MR, Browne JA (2012) Obstructive sleep apnea as a risk factor for postoperative complications after revision joint arthroplasty. J Arthroplasty 27(8 Suppl):95–98. doi: 10.1016/j.arth.2012.03.025 CrossRefPubMedGoogle Scholar
  18. 18.
    Ko LJ, Dehart ML, Yoo JU, Huff TW (2014) Popliteal Artery Injury Associated With Total Knee Arthroplasty: Trends, Costs and Risk Factors. J Arthroplasty. doi: 10.1016/j.arth.2014.01.007 Google Scholar
  19. 19.
    Elixhauser A, Steiner C, Harris DR, Coffey RM (1998) Comorbidity measures for use with administrative data. Med Care 36(1):8–27CrossRefPubMedGoogle Scholar
  20. 20.
    Nikkel LE, Fox EJ, Black KP, Davis C, Andersen L, Hollenbeak CS (2012) Impact of comorbidities on hospitalization costs following hip fracture. J Bone Joint Surg Am 94(1):9–17. doi: 10.2106/JBJS.J.01077 CrossRefPubMedGoogle Scholar
  21. 21.
    Rasouli MR, Maltenfort MG, Purtill JJ, Hozack WJ, Parvizi J (2013) Has the rate of in-hospital infections after total joint arthroplasty decreased? Clin Orthop Relat Res 471(10):3102–3111. doi: 10.1007/s11999-013-2949-z CrossRefPubMedCentralPubMedGoogle Scholar
  22. 22.
    Brass LM, Hartigan PM, Page WF, Concato J (1996) Importance of cerebrovascular disease in studies of myocardial infarction. Stroke 27(7):1173–1176PubMedGoogle Scholar
  23. 23.
    Khot UN, Khot MB, Bajzer CT, Sapp SK, Ohman EM, Brener SJ, Ellis SG, Lincoff AM, Topol EJ (2003) Prevalence of conventional risk factors in patients with coronary heart disease. JAMA 290(7):898–904. doi: 10.1001/jama.290.7.898 CrossRefPubMedGoogle Scholar
  24. 24.
    Reishtein JL (2011) Obstructive sleep apnea: a risk factor for cardiovascular disease. J Cardiovasc Nurs 26(2):106–116. doi: 10.1097/JCN.0b013e3181e3d724 CrossRefPubMedGoogle Scholar
  25. 25.
    Memtsoudis SG, Danninger T, Rasul R, Poeran J, Gerner P, Stundner O, Mariano ER, Mazumdar M (2014) Inpatient falls after total knee arthroplasty: the role of anesthesia type and peripheral nerve blocks. Anesthesiology 120(3):551–563. doi: 10.1097/ALN.0000000000000120 CrossRefPubMedGoogle Scholar
  26. 26.
    Bozic KJ, Wagie A, Naessens JM, Berry DJ, Rubash HE (2006) Predictors of discharge to an inpatient extended care facility after total hip or knee arthroplasty. J Arthroplasty 21(6 Suppl 2):151–156. doi: 10.1016/j.arth.2006.04.015 CrossRefPubMedGoogle Scholar
  27. 27.
    Eisler T, Svensson O, Tengstrom A, Elmstedt E (2002) Patient expectation and satisfaction in revision total hip arthroplasty. J Arthroplasty 17(4):457–462CrossRefPubMedGoogle Scholar
  28. 28.
    Mahomed NN, Barrett JA, Katz JN, Phillips CB, Losina E, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA (2003) Rates and outcomes of primary and revision total hip replacement in the United States medicare population. J Bone Joint Surg Am 85-A(1):27–32PubMedGoogle Scholar
  29. 29.
    Memtsoudis SG, Gonzalez Della Valle A, Besculides MC, Gaber L, Laskin R (2009) Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty. J Arthroplasty 24(4):518–527. doi: 10.1016/j.arth.2008.01.307 CrossRefPubMedGoogle Scholar
  30. 30.
    Eeg-Olofsson K, Cederholm J, Nilsson PM, Zethelius B, Nunez L, Gudbjornsdottir S, Eliasson B (2009) Risk of cardiovascular disease and mortality in overweight and obese patients with type 2 diabetes: an observational study in 13,087 patients. Diabetologia 52(1):65–73. doi: 10.1007/s00125-008-1190-x CrossRefPubMedGoogle Scholar
  31. 31.
    Hanefeld M, Fischer S, Julius U, Schulze J, Schwanebeck U, Schmechel H, Ziegelasch HJ, Lindner J (1996) Risk factors for myocardial infarction and death in newly detected NIDDM: the Diabetes Intervention Study, 11-year follow-up. Diabetologia 39(12):1577–1583CrossRefPubMedGoogle Scholar
  32. 32.
    Meehan JP, Danielsen B, Tancredi DJ, Kim S, Jamali AA, White RH (2011) A population-based comparison of the incidence of adverse outcomes after simultaneous-bilateral and staged-bilateral total knee arthroplasty. J Bone Joint Surg Am 93(23):2203–2213. doi: 10.2106/JBJS.J.01350 CrossRefPubMedGoogle Scholar
  33. 33.
    Restrepo C, Parvizi J, Dietrich T, Einhorn TA (2007) Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Joint Surg Am 89(6):1220–1226. doi: 10.2106/JBJS.F.01353 CrossRefPubMedGoogle Scholar
  34. 34.
    Memtsoudis SG, Besculides MC, Reid S, Gaber-Baylis LK, Gonzalez Della Valle A (2009) Trends in bilateral total knee arthroplasties: 153,259 discharges between 1990 and 2004. Clin Orthop Relat Res 467(6):1568–1576. doi: 10.1007/s11999-008-0610-z CrossRefPubMedCentralPubMedGoogle Scholar
  35. 35.
    Memtsoudis SG, Mantilla CB, Parvizi J, Stundner O, Mazumdar M (2013) Have bilateral total knee arthroplasties become safer? A population-based trend analysis. Clin Orthop Relat Res 471(1):17–25. doi: 10.1007/s11999-012-2608-9 CrossRefPubMedCentralPubMedGoogle Scholar
  36. 36.
    Saito S, Tokuhashi Y, Ishii T, Mori S, Hosaka K, Taniguchi S (2010) One- versus two-stage bilateral total hip arthroplasty. Orthopedics 33 (8). doi: 10.3928/01477447-20100625-07
  37. 37.
    Trojani C, d’Ollonne T, Saragaglia D, Vielpeau C, Carles M, Prudhon JL, French Society for H, Knee (2012) One-stage bilateral total hip arthroplasty: functional outcomes and complications in 112 patients. Orthop Traumatol Surg Res 98(6 Suppl):S120–123. doi: 10.1016/j.otsr.2012.06.008 CrossRefPubMedGoogle Scholar
  38. 38.
    Fu D, Li G, Chen K, Zeng H, Zhang X, Cai Z (2013) Comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: a systematic review of retrospective studies. J Arthroplasty 28(7):1141–1147. doi: 10.1016/j.arth.2012.09.023 CrossRefPubMedGoogle Scholar
  39. 39.
    Belmar CJ, Barth P, Lonner JH, Lotke PA (1999) Total knee arthroplasty in patients 90 years of age and older. J Arthroplasty 14(8):911–914CrossRefPubMedGoogle Scholar
  40. 40.
    Heisler M, Smith DM, Hayward RA, Krein SL, Kerr EA (2003) Racial disparities in diabetes care processes, outcomes, and treatment intensity. Med Care 41(11):1221–1232. doi: 10.1097/01.MLR.0000093421.64618.9C CrossRefPubMedGoogle Scholar
  41. 41.
    Chen J, Rathore SS, Radford MJ, Wang Y, Krumholz HM (2001) Racial differences in the use of cardiac catheterization after acute myocardial infarction. N Engl J Med 344(19):1443–1449. doi: 10.1056/NEJM200105103441906 CrossRefPubMedGoogle Scholar
  42. 42.
    Bang H, Chiu YL, Memtsoudis SG, Mandl LA, Della Valle AG, Mushlin AI, Marx RG, Mazumdar M (2010) Total hip and total knee arthroplasties: trends and disparities revisited. Am J Orthop (Belle Mead NJ) 39(9):E95–102Google Scholar
  43. 43.
    Memtsoudis SG, Besculides MC, Gaber L, Liu S, Gonzalez Della Valle A (2009) Risk factors for pulmonary embolism after hip and knee arthroplasty: a population-based study. Int Orthop 33(6):1739–1745. doi: 10.1007/s00264-008-0659-z CrossRefPubMedCentralPubMedGoogle Scholar
  44. 44.
    Gasior M, Slonka G, Wilczek K, Gierlotka M, Ruzyllo W, Zembala M, Osadnik T, Dubiel J, Zdrojewski T, Kalarus Z, Polonski L (2011) Comparison of invasive and noninvasive treatment strategies in older patients with acute myocardial infarction complicated by cardiogenic shock (from the Polish Registry of Acute Coronary Syndromes - PL-ACS). Am J Cardiol 107(1):30–36. doi: 10.1016/j.amjcard.2010.08.039 CrossRefPubMedGoogle Scholar
  45. 45.
    Memtsoudis SG (2009) Limitations associated with the analysis of data from administrative databases. Anesthesiology 111(2):449. doi: 10.1097/ALN.0b013e3181adf739, author reply 450–441CrossRefPubMedGoogle Scholar
  46. 46.
    Roelands J, Jamison MG, Lyerly AD, James AH (2009) Consequences of smoking during pregnancy on maternal health. J Womens Health (Larchmt) 18(6):867–872. doi: 10.1089/jwh.2008.1024 CrossRefGoogle Scholar
  47. 47.
    Parvizi J, Mui A, Purtill JJ, Sharkey PF, Hozack WJ, Rothman RH (2007) Total joint arthroplasty: When do fatal or near-fatal complications occur? J Bone Joint Surg Am 89(1):27–32. doi: 10.2106/JBJS.E.01443 CrossRefPubMedGoogle Scholar

Copyright information

© SICOT aisbl 2014

Authors and Affiliations

  • Mariano E. Menendez
    • 1
    Email author
  • Stavros G. Memtsoudis
    • 2
  • Marion Opperer
    • 3
  • Friedrich Boettner
    • 3
  • Alejandro Gonzalez Della Valle
    • 3
  1. 1.Department of Orthopaedic SurgeryMassachusetts General HospitalBostonUSA
  2. 2.Department of AnesthesiologyHospital for Special SurgeryNew YorkUSA
  3. 3.Department of Orthopaedic SurgeryHospital for Special SurgeryNew YorkUSA

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