Life Expectancy After Total Hip Arthroplasty
Sven Holmberg,
MD
Abstract: The 6-year survival rate was investigated in 646 patients undergoing total hip arthroplasty for osteoarthritis, rheumatoid arthritis, or complications following femoral neck fracture between 1978 and 1982. A comparison of mortality was done between patients treated by osteosynthesis for fresh femoral neck fracture and a matched general population. The mortality was lower than that of the matched general population after total hip arthroplasty and even lower for patients treated for fresh femoral neck fracture. Patients undergoing total hip arthroplasty for osteoarthritis had the highest survival rate, followed by patients with rheumatoid arthritis and complications after femoral neck fractures. Key words: mortality, survival rate, total hip arthroplasty.
More than 9,000 total hip arthroplasties (THA) are performed in Sweden annually. The main indications are osteoarthritis, rheumatoid arthritis, and sequelae after femoral neck fracture. 3,7,12,14 These groups of patients have previously been extensively analyzed concerning the outcome of the arthroplasty itself, but separate studies of mortality among THA patients so far have not been published. This prospective investigation analyzes the mortality rate and the factors that are associated with mortality among patients w h o have undergone THA. The mortality rate is compared to that of patients with fresh femoral neck fractures and to a matched general population.
Patients w h o u n d e r w e n t bilateral THA and revision arthroplasty were excluded from the study. The majority of the operations were performed u n d e r spinal or epidural anesthesia. The f o l l o w - u p time was a m i n i m u m of 6 years for all surviving patients. All patients were operated on an elective basis. The preoperative assessment was carried out 1 week prior to operation; this included laboratory tests (Hb, ESR, potassium/S, sodium/S, blood grouping, and creatinine/S), electrocardiography, chest radiograph, anesthetic consultation, and medical consultation, w h e n appropriate. Only medically fit or optimized patients according to the preoperative assessment qualified for THA. As prophylaxis against thromboembolism, 6% dextran 70 (Macrodex) was given beginning on the day of surgery and for 3 days afterwards. All Swedish citizens are registered at the Central Bureau of Personal Registration and have an identification number. By means of this central computing system, all other patients w h o had died w i t h i n 6 years after THA were identified and their survival time calculated. In addition, hospital mortality (5 cases) was registered by examination of the hospital records of the patients at the orthopedic department. Two groups were used as controls (1) patients treated
Materials and Methods All 646 patients over 40 years of age (mean, 67 years), u n d e r g o i n g THA from J a n u a r y 1, 1978 through June 3 l, I982 were included in this study. From the Department of Orthopaedics, Samaritan Hospital, Uppsala, Sweden. Reprint requests: Sven Holmberg, MD, Department of Orthopaedics, Samaritan Hospital, P.O. Box 609, S-751 25, Uppsala, Sweden.
183
184
The Journal of Arthroplasty Vol. 7 No. 2 June 1992 T a b l e l . Primary Total H i p A r t h r o p l a s t y P a t i e n t s , b y D i a g n o s i s Age (Years)
OA RA SFNF
Gender
No.
Mean
Range
518 38 90
67 61 69
40-88 40-79 45-91
;
Prosthesis
Male
Female
Carnley
Stanmore
Others
198 16 24
320 22 45
328 20 51
165 I6 32
34 2 7
OA, osteoarthritis; RA, rheumatoid arthritis; SFNF, sequelae following femoral neck fractures. primarily with osteosynthesis for fresh femoral neck fractures during 1 9 7 8 - 1 9 8 0 (673 patients 40 years of age or above; m e a n age, 74 years); (2) an age- and sex-matched general population above 40 years of age from the same catchment area as the studied patients. Life tables for this population were computed based on data furnished by the Swedish Central Bureau of Statistics and weighted survival Curves were constructed. The indications for THA were osteoarthritis in 518 patients (mean age, 67 years) and rheumatoid arthritis in 38 patients (mean age, 61 years) (Table l). All patients with osteoarthritis and rheumatoid arthritis were admitted from their o w n homes. A further 90 patients (mean age, 69 years) underwent operation for sequelae following femoral neck fractures (Table 1). One-fifth of these were admitted from institutions. In 390 patients a Charnley THA was performed, 213 had Stanmore prostheses, and the remaining 43 patients were treated with miscellaneous arthroplasties (Table 1). Differences b e t w e e n the groups were statistically evaluated using chi-square tests with Yates' correction.
up to 6 years (21% compared to 15%) (Table 2, Fig. 1). This difference however, was not significant (P < .4). At 6 years the cumulative mortality rate for the osteoarthritis and rheumatoid arthritis groups was less than half that of the 36% expected for the general population (osteoarthritis, 15%, P < .001; r h e u m a toid arthritis, 21%, P < .02), whereas that of femoral neck fracture group (31%, P < .5) was similar to that of the general population (Table 2, Fig. I). The mortality rate at 6 years was significantly lower for all three patient groups undergoing THA compared to patients having p r i m a r y operations for femoral neck fracture (46%, P < .01). This was most obvious during the first 3 months postoperatively (Fig. 1). No mortality a m o n g patients below 50 years of age was seen within 6 years after THA (Table 3). After 50 years of age the mortality rate increased with age except for the rheumatoid arthritis group, w h i c h did not include patients over 79 years of age (Table 3). The highest mortality rate was recorded a m o n g femoral neck fracture patients a b o v e 80 years of age (50%) (Table 3). Table 4 shows the causes of d e a t h in the three groups. The most c o m m o n single cause of death in osteoarthritis patients was m a l i g n a n c y (20.5%) (Table 4). No deaths due to m a l i g n a n c y were recorded a m o n g patients with rheumatoid arthritis or femoral neck fractures, in w h i c h cardiovascular diseases were the p r e d o m i n a n t cause of d e a t h (77.8% and 52.3%, respectively) (Table 4).
Results Five (0.8%) hospital deaths were recorded, two (0.3%) due to p u l m o n a r y embolism, two due to cardiac infarction, and one due to cerebral hemorrhage. Patients w i t h r h e u m a t o i d arthritis h a d the lowest mortality rate up to 3 years after THA (Table 2, Fig. 1). Following these 3 years the mortality rate increased, s o m e w h a t more rapidly for the rheumatoid arthritis patients than for the osteoarthritis patients,
Discussion The proportion osteoarthritis, r h e u m a t o i d arthritis, and femoral neck fractures, as well as the sex and age distribution in this study, was comparable to that
T a b l e 2. C u m u l a t i v e M o r t a l i t y R e l a t e d to T i m e After T H A a n d D i a g n o s i s 3 Mo
OA RA SFNF Total
No.
NO.
518 38 90 646
11 0 4 15
%
2 0 4 2
6 Mo NO.
13 0 6 19
1 Yr
2 Yr
3 Yr
4 Yr
5 Yr
6 Yr
%
No.
%
No.
%
NO.
%
No.
%
No.
%
No.
%
3 0 7 3
23 0 10 33
4 0 11 5
28 1 14 43
5 3 16 7
38 3 21 62
7 8 23 10
50 5 24 79
10 13 27 12
63 6 26 95
12 16 29 15
77 8 28 113
15 21 31 18
OA, osteoarthritis; RA, rheumatoid arthritis; SFNF, sequelae followingfemoral neck fractures.
Life Expectancy After THA Mortality
rate
Survival
m~-~--.-.~_m ~_~_~
70
\ 40,
.60
HO
150 "~
.
6
1"2
2"4
.
48 72 IVIo n t h s
Fig. 1. Survival rates within 6 years for patients undergoing total hip arthroplasty following osteoarthritis m, rheumatoid arthritis *, and complications after femoral neck fracture O. Mean death risk among a matched general population • and patients with fresh femoral neck fracture ~.
reported in other s t u d i e s . 3,7A2A4 Only five (0.8%) deaths related to the operation were recorded. This low mortality rate may reflect the importance of a well-performed preoperative assessment of the patients. The higher survival rate for THA patients compared to that for the general population could be explained by the fact that all the THA patients were planned for elective surgery. The preoperative medical assessment excluded high cardiac and cardiovascular risk patients, as well as patients in generally bad medical condition, from surgery. The remaining patients were a selected group of medically fit persons who were qualified for surgery. The survival rate was higher among patients undergoing operations for osteoarthritis compared to that among patients reoperated after failed femoral neck fractures.
Table
3. C u m u l a t i v e M o r t a l i t y 6 Years A f t e r T H A b y A g e a n d Diagnosis Rheumatoid Osteoarthritis
Arthritis
Died
Holmberg
185
The most likely reason may be that the osteoarthritis patients were all admitted from their own homes, indicating a better general condition than the femoral neck fracture group, which included patients from institutions.6 A rather high mortality rate among persons affected by rheumatoid arthritis, compared to that of the general population, has been reported by Allebeck.~ This finding was, however, not supported by the present investigation but found to correspond to results reported by Poss and colleagues. 11 The patients who were lest affected by rheumatoid arthritis may be the most active and consequently the ones requesting THA. This may also further emphasize that the rheumatoid arthritis patients undergoing surgery for THA were medically fit. Another possible reason for the low mortality rate among rheumatoid arthritis patients may be that malignancy did not cause death in that group. This is consistent with the findings of Koota and colleagues, 9 who reported a lower mortality rate for cancer in persons suffering from rheumatoid arthritis compared to a control group. The lower mortality rate in failed femoral neck fracture patients compared to that in patients with fresh femoral neck fractures may have several explanations. Patients undergoing emergency operations following fresh femoral neck fractures are often elderly and have concomitant diseases associated with higher surgical and postoperative mortality than those having elective procedures. 4"6 In the latter group, high-risk patients can be discouraged from surgery, whereas patients with a hip fracture normally have to be operated on even if the risk is high. Most of these patients die within 3 months postoperatively, and not until 12 months does the mortality rate equal that of the general population. 6 Patients who qualify for reoperation of a complicated hip fracture seem to be those living active lives, which means they are in good general condition and are probably better suited for an operation. At the beginning of the THA era pulmonary embolism was the most common cause of death following THA. 8,13 Fatal pul-
rate
30
•
Fracture Complication
Died
Age
No.
No.
%
No.
No.
30-49 50-64 65-79 80-99 Total
36 i47 310 25 518
0 14 55 8 77
0 10 I8 32 15
8 12 18 0 38
0 2 6 0 8
% 0 17 33 0 21
Total
Died
Died
No.
No.
%
No.
No.
%
2 28 48 i2 90
0 7 15 6 28
0 25 33 50 3i
46 187 376 37 646
0 23 76 14 113
-I2 20 38 18
186 The Journal of Arthroplasty Vol. 7 No. 2 June 1992 T a b l e 4. Causes of Death Within 6 Years of THA
Fracture
Myocardial infarction Pneumonia Pulmonary embolus Cardiac failure Arteriosderosis Malignancy Cerebral insultus Miscellaneous Total
Total
Osteoarthritis (n = 518)
Rheumatoid Arthritis (n = 38)
Complication
(n = 90)
No.
%*
14 11 5 14 10 17 7 5 83
3 1 -2 1 -1 1 9
2 3 -4 4 6 1 1 21
19 15 5 I9 15 23 9 8 lI3
17 13 7 17 13 20 i3 7 100
* Percent of all deceased.
m o n a r y e m b o l i s m o c c u r r e d in five p a t i e n t s in this series, all in t h e o s t e o a r t h r i t i s g r o u p . T w o of t h o s e p a t i e n t s d i e d d u r i n g t h e h o s p i t a l stay w i t h i n 3 w e e k s of o p e r a t i o n . This is a l o w figure b u t agrees w e l l w i t h r e c e n t f i n d i n g s of a v e r y l o w i n c i d e n c e of p o s t o p e r a tive t h r o m b o e m b o l i s m f o l l o w i n g T H A p e r f o r m e d u n d e r e p i d u r a l o r s p i n a l a n e s t h e s i a m a n d t h e use of p r o p h y l a x i s a g a i n s t t h r o m b o e m b o l i s m . 2"4 These r o u tines w e r e u s e d in this study. I n c o n c l u s i o n , this s t u d y h a s s h o w n t h a t total h i p a r t h r o p l a s t y s e e m s to b e a justifiable p r o c e d u r e e v e n in v e r y o l d p e r s o n s w i t h o u t risking a h i g h m o r t a l i t y r a t e . T h e r e a s o n for t h a t s e e m s to b e a w e l l - p e r f o r m e d p r e o p e r a t i v e a s s e s s m e n t of the p a t i e n t s before surgery. Patients undergoing total hip a r t h r o p l a s t y , w h e t h e r d u e to osteoarthritis, r h e u m a t o i d arthritis, Or failed f e m o r a l n e c k fracture, are g e n erally h e a l t h i e r t h a n a c o m p a r a b l e g r o u p of p e r s o n s in t h e g e n e r a l p o p u l a t i o n .
References I. Allebeck P: Increased mortality in rheumatoid arthritis. Scan J Rheumatol 11:81, 1983 2. Balderston RA, Graham TS, Rooth RE Jr, Rothman RH: The prevention of pulmonary embolism in total hip arthroplasty. J Arthroplasty 4:217, 1989 3. Carlsson AS: 351 total hip replacements according to Charnley: a review of complications and functions. Acta Orthop Scand 52:339, 1981
4. Cogbill CL: Operations in the aged. Arch Surg 94:202, 1967 5. Fredin HO, Nilleus AS: Fatal p u l m o n a r y embolism after total hip replacement. Acta Othop Scand 53:407, 1982 6. Holmberg S, Conradi P, Kalen R, Thorngren K-G: Mortality after cervical hip fractures: 3002 patients followed for 6 years. Acta Orthop Scand 57:8, I986 7. Jacobsson S-A, Djerf K and Wahlstr6m O: A comparative study b e t w e e n M c K e e - F a r r a r and Charnley arthroplasty with long-term follow-up periods. J Arthroplasty 5: I, 1990 8. Johnson R, Green JR, Charnley J: Pulmonary embolism and its prophylaxis following the Charnley total hip replacement. Clin Orthop 127:123, 1977 9. Kooto K, Isom~iki H, Mutn O: Death rate and causes of death in RA patients during a period of five years. Scan J Rheumatol 6:241, 1977 10. McKenzie PJ, Wishart HY, Dewar KMS et al: Comparison of the effects of spinal anaesthesia and general anaesthesia on postoperative oxygenation and perioperative mortality. Br J Anaesth 52:49, 1980 11. Poss R, Maloney JP, Ewald FC et al: Six- to l l - y e a r result of total hip arthroplasty in rheumatoid arthritis. Clin Orthop 182:109, 1983 12. Salvati EA, Wilson Jr PD, Jolley MN et al: A ten-year follow-up study of our first one hundred consecutive Charnley total hip replacements. J Bone Joint Surg 63A:753, 1981 13. Salzman EW, Harris WH: Prevention of venous t h r o m b o e m b o l i s m in orthopaedic patients. J Bone Joint Surg 58A:903, 1976 14. Wejkner B: Long-term results of Charnley total hip replacement. Thesis, Karolinska Institutet, Stockholm, Sweden, 1987
Sven Holmberg,
MD
Abstract: The 6-year survival rate was investigated in 646 patients undergoing total hip arthroplasty for osteoarthritis, rheumatoid arthritis, or complications following femoral neck fracture between 1978 and 1982. A comparison of mortality was done between patients treated by osteosynthesis for fresh femoral neck fracture and a matched general population. The mortality was lower than that of the matched general population after total hip arthroplasty and even lower for patients treated for fresh femoral neck fracture. Patients undergoing total hip arthroplasty for osteoarthritis had the highest survival rate, followed by patients with rheumatoid arthritis and complications after femoral neck fractures. Key words: mortality, survival rate, total hip arthroplasty.
More than 9,000 total hip arthroplasties (THA) are performed in Sweden annually. The main indications are osteoarthritis, rheumatoid arthritis, and sequelae after femoral neck fracture. 3,7,12,14 These groups of patients have previously been extensively analyzed concerning the outcome of the arthroplasty itself, but separate studies of mortality among THA patients so far have not been published. This prospective investigation analyzes the mortality rate and the factors that are associated with mortality among patients w h o have undergone THA. The mortality rate is compared to that of patients with fresh femoral neck fractures and to a matched general population.
Patients w h o u n d e r w e n t bilateral THA and revision arthroplasty were excluded from the study. The majority of the operations were performed u n d e r spinal or epidural anesthesia. The f o l l o w - u p time was a m i n i m u m of 6 years for all surviving patients. All patients were operated on an elective basis. The preoperative assessment was carried out 1 week prior to operation; this included laboratory tests (Hb, ESR, potassium/S, sodium/S, blood grouping, and creatinine/S), electrocardiography, chest radiograph, anesthetic consultation, and medical consultation, w h e n appropriate. Only medically fit or optimized patients according to the preoperative assessment qualified for THA. As prophylaxis against thromboembolism, 6% dextran 70 (Macrodex) was given beginning on the day of surgery and for 3 days afterwards. All Swedish citizens are registered at the Central Bureau of Personal Registration and have an identification number. By means of this central computing system, all other patients w h o had died w i t h i n 6 years after THA were identified and their survival time calculated. In addition, hospital mortality (5 cases) was registered by examination of the hospital records of the patients at the orthopedic department. Two groups were used as controls (1) patients treated
Materials and Methods All 646 patients over 40 years of age (mean, 67 years), u n d e r g o i n g THA from J a n u a r y 1, 1978 through June 3 l, I982 were included in this study. From the Department of Orthopaedics, Samaritan Hospital, Uppsala, Sweden. Reprint requests: Sven Holmberg, MD, Department of Orthopaedics, Samaritan Hospital, P.O. Box 609, S-751 25, Uppsala, Sweden.
183
184
The Journal of Arthroplasty Vol. 7 No. 2 June 1992 T a b l e l . Primary Total H i p A r t h r o p l a s t y P a t i e n t s , b y D i a g n o s i s Age (Years)
OA RA SFNF
Gender
No.
Mean
Range
518 38 90
67 61 69
40-88 40-79 45-91
;
Prosthesis
Male
Female
Carnley
Stanmore
Others
198 16 24
320 22 45
328 20 51
165 I6 32
34 2 7
OA, osteoarthritis; RA, rheumatoid arthritis; SFNF, sequelae following femoral neck fractures. primarily with osteosynthesis for fresh femoral neck fractures during 1 9 7 8 - 1 9 8 0 (673 patients 40 years of age or above; m e a n age, 74 years); (2) an age- and sex-matched general population above 40 years of age from the same catchment area as the studied patients. Life tables for this population were computed based on data furnished by the Swedish Central Bureau of Statistics and weighted survival Curves were constructed. The indications for THA were osteoarthritis in 518 patients (mean age, 67 years) and rheumatoid arthritis in 38 patients (mean age, 61 years) (Table l). All patients with osteoarthritis and rheumatoid arthritis were admitted from their o w n homes. A further 90 patients (mean age, 69 years) underwent operation for sequelae following femoral neck fractures (Table 1). One-fifth of these were admitted from institutions. In 390 patients a Charnley THA was performed, 213 had Stanmore prostheses, and the remaining 43 patients were treated with miscellaneous arthroplasties (Table 1). Differences b e t w e e n the groups were statistically evaluated using chi-square tests with Yates' correction.
up to 6 years (21% compared to 15%) (Table 2, Fig. 1). This difference however, was not significant (P < .4). At 6 years the cumulative mortality rate for the osteoarthritis and rheumatoid arthritis groups was less than half that of the 36% expected for the general population (osteoarthritis, 15%, P < .001; r h e u m a toid arthritis, 21%, P < .02), whereas that of femoral neck fracture group (31%, P < .5) was similar to that of the general population (Table 2, Fig. I). The mortality rate at 6 years was significantly lower for all three patient groups undergoing THA compared to patients having p r i m a r y operations for femoral neck fracture (46%, P < .01). This was most obvious during the first 3 months postoperatively (Fig. 1). No mortality a m o n g patients below 50 years of age was seen within 6 years after THA (Table 3). After 50 years of age the mortality rate increased with age except for the rheumatoid arthritis group, w h i c h did not include patients over 79 years of age (Table 3). The highest mortality rate was recorded a m o n g femoral neck fracture patients a b o v e 80 years of age (50%) (Table 3). Table 4 shows the causes of d e a t h in the three groups. The most c o m m o n single cause of death in osteoarthritis patients was m a l i g n a n c y (20.5%) (Table 4). No deaths due to m a l i g n a n c y were recorded a m o n g patients with rheumatoid arthritis or femoral neck fractures, in w h i c h cardiovascular diseases were the p r e d o m i n a n t cause of d e a t h (77.8% and 52.3%, respectively) (Table 4).
Results Five (0.8%) hospital deaths were recorded, two (0.3%) due to p u l m o n a r y embolism, two due to cardiac infarction, and one due to cerebral hemorrhage. Patients w i t h r h e u m a t o i d arthritis h a d the lowest mortality rate up to 3 years after THA (Table 2, Fig. 1). Following these 3 years the mortality rate increased, s o m e w h a t more rapidly for the rheumatoid arthritis patients than for the osteoarthritis patients,
Discussion The proportion osteoarthritis, r h e u m a t o i d arthritis, and femoral neck fractures, as well as the sex and age distribution in this study, was comparable to that
T a b l e 2. C u m u l a t i v e M o r t a l i t y R e l a t e d to T i m e After T H A a n d D i a g n o s i s 3 Mo
OA RA SFNF Total
No.
NO.
518 38 90 646
11 0 4 15
%
2 0 4 2
6 Mo NO.
13 0 6 19
1 Yr
2 Yr
3 Yr
4 Yr
5 Yr
6 Yr
%
No.
%
No.
%
NO.
%
No.
%
No.
%
No.
%
3 0 7 3
23 0 10 33
4 0 11 5
28 1 14 43
5 3 16 7
38 3 21 62
7 8 23 10
50 5 24 79
10 13 27 12
63 6 26 95
12 16 29 15
77 8 28 113
15 21 31 18
OA, osteoarthritis; RA, rheumatoid arthritis; SFNF, sequelae followingfemoral neck fractures.
Life Expectancy After THA Mortality
rate
Survival
m~-~--.-.~_m ~_~_~
70
\ 40,
.60
HO
150 "~
.
6
1"2
2"4
.
48 72 IVIo n t h s
Fig. 1. Survival rates within 6 years for patients undergoing total hip arthroplasty following osteoarthritis m, rheumatoid arthritis *, and complications after femoral neck fracture O. Mean death risk among a matched general population • and patients with fresh femoral neck fracture ~.
reported in other s t u d i e s . 3,7A2A4 Only five (0.8%) deaths related to the operation were recorded. This low mortality rate may reflect the importance of a well-performed preoperative assessment of the patients. The higher survival rate for THA patients compared to that for the general population could be explained by the fact that all the THA patients were planned for elective surgery. The preoperative medical assessment excluded high cardiac and cardiovascular risk patients, as well as patients in generally bad medical condition, from surgery. The remaining patients were a selected group of medically fit persons who were qualified for surgery. The survival rate was higher among patients undergoing operations for osteoarthritis compared to that among patients reoperated after failed femoral neck fractures.
Table
3. C u m u l a t i v e M o r t a l i t y 6 Years A f t e r T H A b y A g e a n d Diagnosis Rheumatoid Osteoarthritis
Arthritis
Died
Holmberg
185
The most likely reason may be that the osteoarthritis patients were all admitted from their own homes, indicating a better general condition than the femoral neck fracture group, which included patients from institutions.6 A rather high mortality rate among persons affected by rheumatoid arthritis, compared to that of the general population, has been reported by Allebeck.~ This finding was, however, not supported by the present investigation but found to correspond to results reported by Poss and colleagues. 11 The patients who were lest affected by rheumatoid arthritis may be the most active and consequently the ones requesting THA. This may also further emphasize that the rheumatoid arthritis patients undergoing surgery for THA were medically fit. Another possible reason for the low mortality rate among rheumatoid arthritis patients may be that malignancy did not cause death in that group. This is consistent with the findings of Koota and colleagues, 9 who reported a lower mortality rate for cancer in persons suffering from rheumatoid arthritis compared to a control group. The lower mortality rate in failed femoral neck fracture patients compared to that in patients with fresh femoral neck fractures may have several explanations. Patients undergoing emergency operations following fresh femoral neck fractures are often elderly and have concomitant diseases associated with higher surgical and postoperative mortality than those having elective procedures. 4"6 In the latter group, high-risk patients can be discouraged from surgery, whereas patients with a hip fracture normally have to be operated on even if the risk is high. Most of these patients die within 3 months postoperatively, and not until 12 months does the mortality rate equal that of the general population. 6 Patients who qualify for reoperation of a complicated hip fracture seem to be those living active lives, which means they are in good general condition and are probably better suited for an operation. At the beginning of the THA era pulmonary embolism was the most common cause of death following THA. 8,13 Fatal pul-
rate
30
•
Fracture Complication
Died
Age
No.
No.
%
No.
No.
30-49 50-64 65-79 80-99 Total
36 i47 310 25 518
0 14 55 8 77
0 10 I8 32 15
8 12 18 0 38
0 2 6 0 8
% 0 17 33 0 21
Total
Died
Died
No.
No.
%
No.
No.
%
2 28 48 i2 90
0 7 15 6 28
0 25 33 50 3i
46 187 376 37 646
0 23 76 14 113
-I2 20 38 18
186 The Journal of Arthroplasty Vol. 7 No. 2 June 1992 T a b l e 4. Causes of Death Within 6 Years of THA
Fracture
Myocardial infarction Pneumonia Pulmonary embolus Cardiac failure Arteriosderosis Malignancy Cerebral insultus Miscellaneous Total
Total
Osteoarthritis (n = 518)
Rheumatoid Arthritis (n = 38)
Complication
(n = 90)
No.
%*
14 11 5 14 10 17 7 5 83
3 1 -2 1 -1 1 9
2 3 -4 4 6 1 1 21
19 15 5 I9 15 23 9 8 lI3
17 13 7 17 13 20 i3 7 100
* Percent of all deceased.
m o n a r y e m b o l i s m o c c u r r e d in five p a t i e n t s in this series, all in t h e o s t e o a r t h r i t i s g r o u p . T w o of t h o s e p a t i e n t s d i e d d u r i n g t h e h o s p i t a l stay w i t h i n 3 w e e k s of o p e r a t i o n . This is a l o w figure b u t agrees w e l l w i t h r e c e n t f i n d i n g s of a v e r y l o w i n c i d e n c e of p o s t o p e r a tive t h r o m b o e m b o l i s m f o l l o w i n g T H A p e r f o r m e d u n d e r e p i d u r a l o r s p i n a l a n e s t h e s i a m a n d t h e use of p r o p h y l a x i s a g a i n s t t h r o m b o e m b o l i s m . 2"4 These r o u tines w e r e u s e d in this study. I n c o n c l u s i o n , this s t u d y h a s s h o w n t h a t total h i p a r t h r o p l a s t y s e e m s to b e a justifiable p r o c e d u r e e v e n in v e r y o l d p e r s o n s w i t h o u t risking a h i g h m o r t a l i t y r a t e . T h e r e a s o n for t h a t s e e m s to b e a w e l l - p e r f o r m e d p r e o p e r a t i v e a s s e s s m e n t of the p a t i e n t s before surgery. Patients undergoing total hip a r t h r o p l a s t y , w h e t h e r d u e to osteoarthritis, r h e u m a t o i d arthritis, Or failed f e m o r a l n e c k fracture, are g e n erally h e a l t h i e r t h a n a c o m p a r a b l e g r o u p of p e r s o n s in t h e g e n e r a l p o p u l a t i o n .
References I. Allebeck P: Increased mortality in rheumatoid arthritis. Scan J Rheumatol 11:81, 1983 2. Balderston RA, Graham TS, Rooth RE Jr, Rothman RH: The prevention of pulmonary embolism in total hip arthroplasty. J Arthroplasty 4:217, 1989 3. Carlsson AS: 351 total hip replacements according to Charnley: a review of complications and functions. Acta Orthop Scand 52:339, 1981
4. Cogbill CL: Operations in the aged. Arch Surg 94:202, 1967 5. Fredin HO, Nilleus AS: Fatal p u l m o n a r y embolism after total hip replacement. Acta Othop Scand 53:407, 1982 6. Holmberg S, Conradi P, Kalen R, Thorngren K-G: Mortality after cervical hip fractures: 3002 patients followed for 6 years. Acta Orthop Scand 57:8, I986 7. Jacobsson S-A, Djerf K and Wahlstr6m O: A comparative study b e t w e e n M c K e e - F a r r a r and Charnley arthroplasty with long-term follow-up periods. J Arthroplasty 5: I, 1990 8. Johnson R, Green JR, Charnley J: Pulmonary embolism and its prophylaxis following the Charnley total hip replacement. Clin Orthop 127:123, 1977 9. Kooto K, Isom~iki H, Mutn O: Death rate and causes of death in RA patients during a period of five years. Scan J Rheumatol 6:241, 1977 10. McKenzie PJ, Wishart HY, Dewar KMS et al: Comparison of the effects of spinal anaesthesia and general anaesthesia on postoperative oxygenation and perioperative mortality. Br J Anaesth 52:49, 1980 11. Poss R, Maloney JP, Ewald FC et al: Six- to l l - y e a r result of total hip arthroplasty in rheumatoid arthritis. Clin Orthop 182:109, 1983 12. Salvati EA, Wilson Jr PD, Jolley MN et al: A ten-year follow-up study of our first one hundred consecutive Charnley total hip replacements. J Bone Joint Surg 63A:753, 1981 13. Salzman EW, Harris WH: Prevention of venous t h r o m b o e m b o l i s m in orthopaedic patients. J Bone Joint Surg 58A:903, 1976 14. Wejkner B: Long-term results of Charnley total hip replacement. Thesis, Karolinska Institutet, Stockholm, Sweden, 1987
