The Journal of Arthroplasty xxx (2015) xxx–xxx

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Perioperative Complications and Length of Stay After Revision Total Hip and Knee Arthroplasties: An Analysis of the NSQIP Database Emmanouil Liodakis, MD , Stephane G. Bergeron, MD, MPH, David J. Zukor, MD, Olga L. Huk, MSc, MD, Laura M. Epure, Eng. MSc, John Antoniou, PhD, MD Jewish General Hospital, McGill University, Montreal, Canada

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Article history: Received 4 March 2015 Accepted 15 May 2015 Available online xxxx Keywords: short-term complications revision total hip arthroplasty revision total knee arthroplasty NSQIP Database length of stay

a b s t r a c t Goals of this study were (1) to determine the 30-day complications after aseptic revision hip arthroplasty (RHA) and aseptic revision knee arthroplasty (RKA) and (2) to identify patient-related risk factors predicting major complications and prolonged hospital stay beyond 7 days. The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients with RHA (n = 2643) or RKA (n = 2425) from 2011 to 2012. The 30-day mortality rates for RHA and RKA were 1.0% and 0.1% (P b 0.001) and the overall complication rates were 7.4% and 4.7% (P b 0.001) for RHA and RKA, respectively. Multivariable analysis showed that preoperative anemia is the most important modifiable independent predictor for both major complications and prolonged hospital stay after RHA and RKA. © 2015 Elsevier Inc. All rights reserved.

With increasing number of patients undergoing primary hip and knee arthroplasties over the past decade, the rate of revision hip arthroplasty (RHA) and revision knee arthroplasty (RKA) will inevitably increase [1,2]. Based on discharge data from the National Hospital Discharge Survey, the total number of revision procedures almost doubled for revision hip surgeries and tripled for revision knee surgeries from 1990 to 2002 [3]. The revision burden, defined as the ratio of revision to the sum of revision and primary procedures, has been estimated to be 8.2% for TKA and 17.5% for THA from 1990 to 2002 [3]. Despite the large numbers of RHA and RKA performed annually, there are little data on early morbidity and complications after RHA and RKA [4]. In a nationwide Denmark study, the authors analyzed 1553 aseptic RHA over a 2 year period showing a readmission rate of 18.3%, a dislocation rate of 7% and a mortality rate of 1.4% within 90 days of surgery [5]. However, very little is known regarding the risk factors associated with post-operative complications or prolonged length of stay following revision hip and knee arthroplasties. The objectives of this study are (1) to determine the overall 30-day morbidity and mortality after aseptic RHA and RKA and (2) to identify

Each author certifies that all investigations were conducted in conformity with ethical principles of research. This work was performed at the Jewish General Hospital, Montreal, Canada. Source of Funding: No funding was received in support of this study. One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.05.029. Reprint requests: Emmanouil Liodakis, MD, Orthopedic Surgeon, Chercheur National FRSQ, Jewish General Hospital, 3755 Cote-St. Catherine Road, H3T 1E2 Montreal, Quebec, Canada.

independent patient-related risk factors predicting major complications and prolonged hospital stay. Patients and Methods The American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) collects prospective clinical data on patients undergoing surgical procedures in hospitals across North America. The NSQIP Participant Use Data File provides validated, 30day surgical outcomes. NSQIP data collection methodology has been previously reported elsewhere [6,7]. An analysis of the NSQIP database between 2011 and 2012 was performed. The following American Medical Association Current Procedural Terminology (CPT) codes were used to identify all patients who had aseptic revision hip or knee arthroplasties for all causes: 27134 (revision total hip arthroplasty, both components), 27137 (revision total hip arthroplasty, acetabular component only), 27138 (revision total hip arthroplasty, femoral component only), 27486 (revision total knee arthroplasty, one component) and 27487 (revision of total knee arthroplasty, femoral and entire tibial component). Revisions as a result of periprosthetic joint infections were excluded given that the NSQIP database does not contain details regarding the nature of the infection (acute vs. chronic) or the type of revision (one vs. two-stage procedure). Therefore, patients undergoing removal of a prosthesis with or without the insertion of a spacer (CPT codes 27090, 27091, and 27488) were excluded from the analysis. Patients with preoperative sepsis or septic shock were also excluded. Finally, patients who had missing baseline data were also excluded from the study. Patient-specific factors, including demographics and medical comorbidities, as well as surgical variables were extracted for further analysis.

http://dx.doi.org/10.1016/j.arth.2015.05.029 0883-5403/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Liodakis E, et al, Perioperative Complications and Length of Stay After Revision Total Hip and Knee Arthroplasties: An Analysis of the NSQIP Database, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.029

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E. Liodakis et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx

The rate and type of postoperative complications and mortality within 30 days of surgery were also recorded. Patients having complications were divided into two groups: (1) major – life threatening or death (at least one of the following: pulmonary embolism, cardiac arrest, myocardial infarction, unplanned intubation, sepsis, acute renal failure, cerebrovascular accident, death) and (2) minor – not acutely life threatening (at least one of the following: urinary tract infection, DVT, pneumonia, peripheral nerve injury, superficial wound infection, deep wound infection). The separation of complications into major and minor is based on previous literature using the NSQIP database [8,9]. Since 90% of the patients in the NSQIP database undergoing revision hip and knee arthroplasty were discharged within 7 days postoperatively, prolonged hospital stay was defined as a hospital stay exceeding 7 days. Preoperative anemia was defined according to the definitions from the World Health Organization as a hematocrit less than 35% [10,11]. Patient's age was dichotomized at 75 years (75th percentile). Statistics Continuous variables are reported as mean ± standard deviation (SD) while categorical variables are reported as percentages. Differences between the groups were evaluated using a t-test for continuous data and Fisher's exact test for categorical values. Missing values and variables with a documentation rate b95% were excluded from the analysis. A univariable screen was first performed to identify potential predictors and confounders. Starting with a full model with all 14 variables, independent risk factors for post-operative major complications and prolonged length of stay beyond 7 days were assessed using a multivariable logistic regression model. Subsequent models were created by excluding variables that were believed to be unlikely true confounders. The stability of each model was compared using the − 2 Log L, chisquare likelihood ratio and AIC criterion. The model that best predicted major complication and prolong length of stay was chosen as the final model. The final models for hip and knee as well as both outcomes (major complication and prolong length of stay) differ given that a multivariable logistic regression was performed for each procedure and outcome. The independent effect of each predictor is reported using odds ratios (ORs) and 95% confidence intervals (C.I.). A P-value b 0.05 was considered statistically significant. All statistical analyses were performed using SPSS (SPSS 22.0, IBM Inc., Somers, NY, USA).

Table 1 Patient Demographics and Preoperative Characteristics.

Characteristic Age (years) BMI (kg/m2) Gender (female) Anesthesia technique Regional General ASA ASA 1–2 ASA N2 Diabetes Hypertension Current smoker History of severe COPD Congestive heart failure Bleeding disorders Hematocrit b35% Components revised One component Two components Total operation time (min)

Hip Revision (n = 2643)

Knee Revision (n = 2425)

66.5 ± 13.2 29.4 ± 6.7 56.8%

65.7 ± 11.4 32.7 ± 7.1 60.9%

29.4% 70.6%

36.8% 63.2%

46.5% 53.5% 11.4% 58.4% 14.6% 6.2% 0.7% 5.5% 19.5%

45.2% 54.8% 20.5% 67.3% 11.2% 5.2% 0.6% 4.2% 12.1%

38.4% 61.6% 145.3 ± 79.7

33.4% 66.6% 134.3 ± 68.3

Anesthesiologists (ASA) score N 2, hematocrit b35, COPD, operation time N 180 min and revision of 2 components were independent predictors for a prolonged hospital stay after RHA (Table 4). Independent predictors for a prolonged hospital stay after RKA were ASA N2, hematocrit b35 and history of COPD. A low preoperative hematocrit was the strongest modifiable independent predictor for both major complications and prolonged hospital stay following both RHAs and RKAs. Discussion Data on perioperative complications from large cohorts following RHA and RKA are lacking. The primary purpose of this study was to evaluate 30-day postoperative major complications after RHA or RKA. The

Table 2 Postoperative Data.

Results A total of 5068 patients were included in this study. Revision hip arthroplasty accounted for 52.2% (n = 2643) of patients while the remaining 47.8% of patients underwent revision knee arthroplasty (n = 2425). Both components were revised in 61.6% of hip revision patients and in 66.6% of knee revision patients. Only one component was revised in the remaining patients. The preoperative baseline characteristics of the patients are shown in Table 1. Women accounted for 56.8% and 60.9% of the RHA and RKA groups, respectively. The mean age was 66.5 ± 13.2 years for the RHA group and 65.7 ± 11.4 years for the RKA group. Postoperative data are summarized in Table 2. The 30-day mortality rates were 1.0% and 0.1% for RHAs and RKAs, respectively (P b 0.001). The corresponding overall complication rates were 7.4% for RHA and 4.7% for RKA (P b 0.001). The rate of major complications (including death) was higher for RHA (3.0% vs 1.6%, P = 0.001). Minor complications were also more common in the RHA group (5.1 vs 3.4%, P = 0.002). In addition, RHA-patients required more blood transfusions (34.4% vs 20.7%, P b 0.001) and stayed longer in the hospital (4.1 ± 3.9 days vs 3.4 ± 2.1 days, P b 0.001). Age greater than 75, hypertension, chronic obstructive pulmonary disease (COPD), general anesthesia and preoperative anemia (hematocrit b 35) were predictors for major complications after RHA (Table 3). Age greater than 75 and hematocrit b 35 were independent predictors for major complications after RKA. Age greater than 75, American Society of

Major complications: life threatening or death Sepsis Septic shock Acute renal failure Pulmonary embolism Occurrences ventilator N48 hours Occurrences unplanned intubation Myocardial infarction Cardiac arrest requiring CPR Stroke with neurological deficit Mortality Minor complications: not life threatening Urinary tract infection Pneumonia Superficial surgical site infection Wound dehiscence Peripheral nerve injury Deep wound infection DVT requiring therapy Overall complications rate Adverse events not included in the overall complication rate Intraop/postop transfusions Readmission Postop hospital stay (days) Postop hospital stay N7 days

Hip Revision

Knee Revision

P-Value

3.0% 0.6% 0.1% 0.2% 0.3% 0.3% 0.4% 0.5% 0.3% 0.2% 1.0% 5.1% 1.9% 0.6% 1.3% 0.3% 0.1% 0.9% 0.4% 7.4%

1.6% 0.6% 0.1% 0.0% 0.4% 0.0% 0.1% 0.1% 0.2% 0.2% 0.1% 3.4% 1.0% 0.3% 0.9% 0.2% 0.1% 0.3% 0.7% 4.7%

0.001 1.000 1.000 0.126 0.809 0.072 0.040 0.014 0.585 1.000 b0.001 0.002 0.014 0.099 0.175 0.392 1.000 0.008 0.188 b0.001

34.4% 3.4% 4.1 ± 3.9 10.4%

20.7% 2.2% 3.4 ± 2.1 4.3%

b0.001 0.013 b0.001 b0.001

Boldface values indicate statistical significance (P b 0.05).

Please cite this article as: Liodakis E, et al, Perioperative Complications and Length of Stay After Revision Total Hip and Knee Arthroplasties: An Analysis of the NSQIP Database, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.029

E. Liodakis et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx

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Table 3 Univariable and Multivariable Logistic Regression to Assess Risk Factors for Major Complications in Revision Arthroplasty. Univariable Analysis

Multivariable Analysis

OR

95% CI

P-Value

OR

95% CI

Revision Hip Arthroplasty Male gender Age N75 BMI N30 Smoking ASA N2 Hematocrit b35 Bleeding disorder Hypertension Diabetes Heart failure COPD Operation time N180 min General anesthesia Revision of 2 components

P-Value

1.29 2.76 0.78 0.99 3.09 3.34 2.77 3.07 1.90 3.93 2.68 1.80 2.99 1.00

0.83–2.00 1.76–4.31 0.49–1.24 0.53–1.84 1.82–5.25 2.11–5.28 1.43–5.34 1.77–5.33 1.09–3.32 0.89–17.36 1.42–5.04 1.13–2.87 1.33–5.83 0.64–1.56

0.262 b0.001 0.301 1.000 b0.001 b0.001 0.005 b0.001 0.033 0.11 0.004 0.017 b0.001 1.000

1.29 1.66 0.77 1.61 2.24 1.49 1.95 1.26 2.12 1.60 2.51 1.01

0.80–2.06 1.01–2.75 0.46–1.27 0.89–2.93 1.36–3.69 0.74–3.01 1.08–3.51 0.68–2.33 1.08–4.13 0.98–2.63 1.23–5.12 0.62–1.63

0.294 0.047 0.303 0.118 0.002 0.267 0.027 0.459 0.028 0.060 0.012 0.974

Revision Knee Arthroplasty Male gender Age N75 BMI N30 Smoking ASA N2 Hematocrit b35 Bleeding disorders Hypertension Diabetes Heart failure COPD Operation time N180 min General anesthesia Revision of 2 components

1.24 2.58 1.14 1.30 2.69 3.42 3.82 1.61 1.51 9.63 2.44 1.22 1.00 0.85

0.67–2.27 1.34–4.98 0.59–2.21 0.54–3.10 1.27–5.72 1.66–7.06 1.58–9.27 0.79–3.29 0.77–2.96 2.09–44.42 0.94–6.30 0.57–2.60 0.51–1.94 0.45–1.58

0.530 0.007 0.742 0.472 0.008 0.002 0.009 0.250 0.252 0.024 0.071 0.548 1.000 0.626

1.07 2.20 1.84 1.60 2.53 2.13 1.36 4.34 0.91 1.13

0.53–2.14 1.05–4.58 0.67–5.08 0.71–3.59 1.17–5.46 0.73–6.18 0.56–3.25 0.80–23.42 0.45–1.84 0.55–2.38

0.855 0.036 0.237 0.256 0.018 0.163 0.495 0.088 0.784 0.729

Boldface values indicate statistical significance (P b 0.05).

Table 4 Univariable and Multivariable Logistic Regression to Assess Risk Factors for Prolonged Hospital Stay (N7 Days). Univariable Analysis

Multivariable Analysis

OR

95% CI

P-Value

OR

95% CI

P-Value

Revision Hip Arthroplasty Male gender Age N75 BMI N30 Smoking ASA N2 Hematocrit b35 Bleeding disorder Hypertension Diabetes Heart failure COPD Operation time N180 min General anesthesia Revision of 2 components

0.90 2.49 0.91 0.93 3.19 3.22 2.62 1.46 1.62 4.95 2.49 2.78 1.66 1.26

0.70–1.14 1.93–3.22 0.70–1.19 0.66–1.31 2.38–4.26 2.46–4.21 1.75–3.90 1.14–1.88 1.16–2.25 1.90–12.87 1.69–3.65 2.15––3.60 1.23–2.26 0.98–1.63

0.391 b0.001 0.545 0.730 b0.001 b0.001 b0.001 0.003 0.006 0.003 b0.001 b0.001 0.001 0.070

1.08 1.89 2.14 2.46 1.19 1.24 1.34 1.79 2.57 1.24 1.56

0.82–1.43 1.43–2.50 1.54–2.96 1.83–3.30 0.74–1.91 0.86–1.79 0.43–4.16 1.15–2.78 1.95–3.39 0.89–1.73 1.17–2.10

0.569 b0.001 b0.001 b0.001 0.463 0.259 0.613 0.010 b0.001 0.197 0.003

Revision Knee Arthroplasty Male Gender Age N75 BMI N30 Smoking ASA N2 Hematocrit b35 Bleeding disorders Hypertension Diabetes Heart failure COPD Operation time N180 min General Anesthesia Revision of 2 components

0.77 1.69 1.15 0.72 2.31 4.61 4.12 1.30 1.58 4.73 1.97 1.55 1.21 1.19

0.49–1.23 1.10–2.61 0.76–1.74 0.33–1.57 1.49–3.60 3.00–7.08 2.16–7.87 0.80–2.11 0.97–2.56 1.04–21.49 0.93–4.17 1.00–2.40 0.80–1.84 0.74–1.92

0.306 0.025 0.535 0.483 b0.001 b0.001 b0.001 0.344 0.073 0.082 0.080 0.061 0.407 0.556

0.78 1.32 1.75 3.72 1.79 1.40 2.52 1.37 1.37

0.50–1.21 0.83–2.11 1.07–2.86 2.37–5.84 0.86–3.70 0.89–2.22 1.30–4.89 0.85–2.19 0.85–2.21

0.265 0.237 0.026 b0.001 0.117 0.148 0.006 0.196 0.195

Boldface values indicate statistical significance (P b 0.05).

Please cite this article as: Liodakis E, et al, Perioperative Complications and Length of Stay After Revision Total Hip and Knee Arthroplasties: An Analysis of the NSQIP Database, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.029

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E. Liodakis et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx

secondary objective of this study was to identify independent risk factors contributing to major complications and prolonged hospital stay after undergoing RHA and RKA. The multivariable analysis showed that preoperative anemia and general anesthesia are important modifiable independent predictors for major complications and prolonged hospital stay after RHA and RKA. The most common major complication was sepsis and death while the most common minor complication was urinary tract infection for both revision hip and knee arthroplasties. Urinary tract infection is also the most common minor complication following primary total knee or hip arthroplasties, with similar rates to those reported in this study [9,12]. Sepsis rates as well as wound infection rates for revision cases were more than two times higher compared to the previously reported rates for primary arthroplasties. The latter is in agreement with other studies and may be explained by the complexity of these cases and unrecognized or occult infections that led to the failure of these cases in the first instance [13]. Given the relatively high rate of life threatening complications (3.0% for RHA and 1.6% for RKA), revision surgeries should be performed in centers with experience in critical care of orthopedic patients [14]. RHAs are associated with a higher rate of overall complications than RKAs (7.4% for RHA and 4.7% for RKA, P b 0.001). However, this is likely an underestimation of the overall complication rate following RHA since dislocations are not reported in NSQIP. Previous studies have shown that hip dislocation is the most common complication following revision hip arthroplasty with a rate of approximately 7–10% [5,15,16]. Using the NSQIP database, we were able to study a large number of patients to identify modifiable and non-modifiable independent risk factors for complications and prolonged hospital stay. According to our results, the most important modifiable risk factor associated with major perioperative complications and prolonged hospital stay was preoperative anemia. This finding is in agreement with prior studies that found anemia to be associated with cardiovascular complications and to be also a predisposing factor for periprosthetic joint infections [13,17–19]. Blood transfusion-related immunomodulation (TRIM) may be one of the main reasons for the association between preoperative anemia and surgical site infection [20]. In addition, a low hematocrit may indicate an underlying disease such as renal failure or cancer. An attempt to correct a low hematocrit, by addressing any underlying causes for anemia should be made prior to revision hip or knee surgery if possible. Further studies need to be done to examine the utility of preoperative blood restoration strategies such as transfusions or erythropoietin. Another important modifiable risk factor for major complications after RHA is general anesthesia. Rodgers et al [21] showed in a systematic review of randomized trials that regional anesthesia was associated with reduced rates of deep vein thrombosis, pulmonary embolism, pneumonia, bleeding complications and mortality. These benefits are explained by multifactorial mechanisms such as increased blood flow and reduction of surgical stress responses. Regional anesthesia should preferably be used for patients undergoing hip revision when possible. Contrary to our results (0.1% mortality after RKA), Dietrich et al [8] found higher 30-day mortality rates for RKAs (0.4%). However, they analyzed septic and aseptic revisions, while we excluded all patients with preoperative sepsis or revisions for periprosthetic joint infections. Differences in major and minor complication rates can be explained by the different definitions used for major/minor complications. For example, we classified wound complications as minor complications because they are not acutely life threatening, while other studies have classified these as major. There are several limitations to this study. First, common short-term complications such as hip dislocations were not reported in the database. Second, use of tourniquet in revision knee arthroplasty is unclear. The use of a tourniquet may explain the lower rate of transfusion following RKA compared to RHA. Third, we were unable to differentiate short-term outcomes on the basis of bone defects, malalignment, im-

plant design or cement status. Fourth, NSQIP does not offer information regarding prior revisions, the exact reason for the revision and length of time between the primary procedure and the revision. Revisions for periprosthetic joint infections were excluded since adequate comparison could not be performed using this database. Lastly, our analysis is limited to short-term (30-day) outcomes since long-term outcomes such as prosthesis survival or late infection rates are not available. This study has also important strengths, including completeness of the database and detailed clinical information. To the best of our knowledge, this is the largest multicenter study analyzing risk factors for postoperative complications and prolonged length of stay following RHA and RKA, using the validated NSQIP Database. Conclusion RHAs are associated with more perioperative complications and require more operative time, more blood transfusions and a longer hospital stay than RKAs. After controlling for all variables, the strongest modifiable risk factor for both major complications and prolonged hospital stay after RHA and RKA was a low preoperative hematocrit. Further studies are needed to analyze the effects of preoperative blood restoration strategies on patient outcome. References 1. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89(4):780. 2. Ong KL, Mowat FS, Chan N, et al. Economic burden of revision hip and knee arthroplasty in Medicare enrollees. Clin Orthop Relat Res 2006;446:22. 3. Kurtz S, Mowat F, Ong K, et al. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am 2005; 87(7):1487. 4. Saleh KJ, Hoeffel DP, Kassim RA, et al. Complications after revision total knee arthroplasty. J Bone Joint Surg Am 2003;85-A(Suppl. 1):S71. 5. Lindberg-Larsen M, Jorgensen CC, Hansen TB, et al. Early morbidity after aseptic revision hip arthroplasty in Denmark: a two-year nationwide study. Bone Joint J 2014;96B(11):1464. 6. Osman F, Saleh F, Jackson TD, et al. Increased postoperative complications in bilateral mastectomy patients compared to unilateral mastectomy: an analysis of the NSQIP database. Ann Surg Oncol 2013;20(10):3212. 7. Shiloach M, Frencher Jr SK, Steeger JE, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg 2010;210(1):6. 8. Dieterich JD, Fields AC, Moucha CS. Short term outcomes of revision total knee arthroplasty. J Arthroplast 2014;29(11):2163. 9. Belmont Jr PJ, Goodman GP, Waterman BR, et al. Thirty-day postoperative complications and mortality following total knee arthroplasty: incidence and risk factors among a national sample of 15,321 patients. J Bone Joint Surg Am 2014;96(1):20. 10. Hales M, Solez K, Kjellstrand C. The anemia of acute renal failure: association with oliguria and elevated blood urea. Ren Fail 1994;16(1):125. 11. Bydon M, Abt NB, Macki M, et al. Preoperative anemia increases postoperative morbidity in elective cranial neurosurgery. Surg Neurol Int 2014;5:156. 12. Fehringer EV, Mikuls TR, Michaud KD, et al. Shoulder arthroplasties have fewer complications than hip or knee arthroplasties in US veterans. Clin Orthop Relat Res 2010; 468(3):717. 13. Rasouli MR, Restrepo C, Maltenfort MG, et al. Risk factors for surgical site infection following total joint arthroplasty. J Bone Joint Surg Am 2014;96(18):e158. 14. Memtsoudis SG, Rosenberger P, Walz JM. Critical care issues in the patient after major joint replacement. J Intensive Care Med 2007;22(2):92. 15. Alberton GM, High WA, Morrey BF. Dislocation after revision total hip arthroplasty: an analysis of risk factors and treatment options. J Bone Joint Surg Am 1788;84A(10):2002. 16. Wetters NG, Murray TG, Moric M, et al. Risk factors for dislocation after revision total hip arthroplasty. Clin Orthop Relat Res 2013;471(2):410. 17. Greenky M, Gandhi K, Pulido L, et al. Preoperative anemia in total joint arthroplasty: is it associated with periprosthetic joint infection? Clin Orthop Relat Res 2012; 470(10):2695. 18. Wu WC, Schifftner TL, Henderson WG, et al. Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery. JAMA 2007; 297(22):2481. 19. Viola J, Gomez MM, Restrepo C, et al. Preoperative anemia increases postoperative complications and mortality following total joint arthroplasty. J Arthroplast 2015; 30(5):846. 20. Park JH, Rasouli MR, Mortazavi SM, et al. Predictors of perioperative blood loss in total joint arthroplasty. J Bone Joint Surg Am 1777;95(19):2013. 21. Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000;321(7275):1493.

Please cite this article as: Liodakis E, et al, Perioperative Complications and Length of Stay After Revision Total Hip and Knee Arthroplasties: An Analysis of the NSQIP Database, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.05.029

Perioperative Complications and Length of Stay After Revision Total Hip and Knee Arthroplasties: An Analysis of the NSQIP Database.

Goals of this study were (1) to determine the 30-day complications after aseptic revision hip arthroplasty (RHA) and aseptic revision knee arthroplast...
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