Abstract
Purpose
To determine the risk factors for complications after hip or knee replacement surgery in elderly patients.
Methods
In total, 401 elderly patients (aged ≥ 65 years) who underwent hip or knee replacement surgery at a hospital from January 2017 to December 2022 were retrospectively analyzed. Univariate analysis was performed to identify significant variables. Risk factors and the effects of the model were examined by unconditional binary logistic regression analyses and receiver operating characteristic (ROC) curve analysis, respectively.
Results
A total of 122 (30.42%) patients were diagnosed with complications after hip or knee replacement surgery, and the independent risk factors for complications were age, body mass index (BMI) and hypertension. Fifty-six patients (13.97%) developed lower extremity venous thrombosis (LEVT), and the independent risk factors were hypertension, surgical joint type and visual analog scale (VAS) pain score. Cardiopulmonary complications occurred in 50 patients (12.47%), and the independent risk factors were age and BMI. Postoperative delirium occurred in 15 patients (3.74%), and its independent risk factors were age and American Society of Anesthesiologists (ASA) grade. Two or more complications occurred in 17 patients (4.24%), and the independent risk factors were age and diabetes.
Conclusions
This study focused on elderly patients with risk factors for complications after hip or knee replacement surgery. Clinically, elderly patients undergoing hip or knee replacement surgery should perform well in terms of preoperative and perioperative management.
Keywords: Replacement, Complications, Risk factors
With the continuous progress in artificial joint prosthesis materials and surgical techniques, hip or knee replacement surgery has gradually become a routine operation for the treatment of end-stage hip and knee joint diseases or certain fractures, and the number of such surgeries is increasing every year [1–3]. Moreover, the age range for treatment is no longer limited [4, 5], and the surgical outcomes have been widely recognized [6, 7]. Advanced age is no longer a contraindication for hip and knee replacement surgery, and the age standard for such surgery has been relaxed to 80 years. A recent study [8] found that strictly adhering to surgical indications in patients over 80 years old for total hip arthroplasty (THA) or total knee arthroplasty (TKA) not only does not affect life expectancy but can also improve their quality of life with satisfactory surgical outcomes. However, as a type of major surgery, hip and knee replacement can cause significant trauma and economic burden to patients if complications occur. Elderly patients are more prone to perioperative complications [6], including infection, venous thromboembolism (VTE), cardiopulmonary complications, dislocation, and periprosthetic fracture, after hip and knee replacement surgery [9–11]. However, there has been no systematic statistical analysis of risk factors for various complications. Most of the studies were analyzed for one complication or specific functional complications after surgery, or for the complications of one joint replacement surgery, and there were few studies on the risk factors of general Complications.
To further clarify the risk factors for complications after hip or knee replacement surgery in elderly patients, this study retrospectively analyzed elderly patients (aged ≥ 65 years) who underwent such surgery in a hospital from January 2017 to December 2022 to determine the risk factors for postoperative complications. The correct identification of early risk factors is not only an effective measure to reduce postoperative complications and ensure the quality and safety of surgery but also a concrete reflection of the medical staff’s ability to manage patients and surgical techniques during the perioperative period.
Data and methods
Patients
Patients who underwent hip or knee replacement surgery at a hospital between January 2017 and December 2022 were included in this study. Surgeries involving prosthetic reconstruction following hip tumor resection were excluded. Hip replacement surgeries included both cementless and cemented THA, as well as partial hip arthroplasty. Knee replacement surgeries included TKA and partial knee arthroplasty [12, 13]. Surgical indications included various forms of arthritis (osteoarthritis, rheumatoid arthritis, traumatic arthritis, etc.) unresponsive to conservative treatment, femoral head osteonecrosis, and joint fractures.
Inclusion criteria: patients aged 65 years and older who were hospitalized for hip or knee replacement surgery and followed up for at least six months.
Exclusion criteria: patients under 65 years of age, incomplete clinical data, and those with severe preoperative cardiovascular or respiratory diseases where symptoms were apparent and could not be controlled despite appropriate treatment.
Risk factors
This retrospective study collected data on sex, age, BMI, disease and surgery type, surgical site, anesthesia method, American Society of Anesthesiologists (ASA) physical status classification, length of stay (LOS), VAS pain score, duration of anesthesia and surgery, surgery start and end times, smoking status, alcohol abuse, blood transfusion, and the presence of chronic conditions such as diabetes and hypertension. These data were used to analyze the risk factors associated with complications after hip or knee arthroplasty.
General complications after hip or knee replacement
Complications considered in this study refer to general medical postoperative complications, such as lower extremity venous thrombosis, cardiovascular events, pulmonary complications, postoperative delirium, incision infection, and complications of the digestive and urinary systems. These do not include specific postoperative functional complications (e.g., stiff TKA, hip dislocation).
Diagnostic criteria were as follows:
Cardiopulmonary complications: the emergence of new cardiac or pulmonary symptoms or signs after surgery, diagnosed based on positive findings from lung CT and electrocardiography.
Postoperative delirium: symptoms such as hyperarousal, irritability, and impaired consciousness occurring after surgery, diagnosed following a neurological consultation.
Lower extremity venous thrombosis: no thrombus detected by preoperative lower extremity venous Doppler ultrasound, but thrombus identified postoperatively via Doppler ultrasound.
Digestive and urinary system complications: newly developed symptoms of gastrointestinal or urinary system disorders post-surgery, diagnosed by the relevant departments.
Statistical analysis
Statistical analysis was performed using SPSS 21.0 (IBM). Continuous variables are expressed as mean ± standard deviation (SD) and analyzed using independent samples t-tests. Categorical variables and rates were compared using analysis of variance (ANOVA). Univariate statistical analysis and clinically significant factors identified by experts were included in the unconditional binomial logistic regression model. A p-value < 0.05 was considered statistically significant. The area under the curve (AUC) was used to evaluate the performance of the logistic regression model; the closer the AUC is to 1.0, the better the model’s predictive ability [14].
Results
Case data
Data from a total of 792 patients were retrospectively collected in this study. Among them, 354 patients were younger than 65 years, 23 patients had incomplete data, and 14 patients with severe pulmonary diseases were excluded. A total of 401 patients (296 females, 73.82%, and 105 males, 26.18%) were included in the study (Fig. 1).
Fig. 1.
Flowchart of the study
Among the patients included in the study, 255 cases (63.59%) were 65 to 74 years old, 116 cases (28.93%) were 75 to 84 years old, and 30 cases (7.48%) were 85 years old and above. There were 222 cases of hip replacement (55.36%) and 179 cases of knee replacement (44.64%). A total of 129 patients (32.17%) underwent emergency surgery, and 274 patients (67.83%) underwent elective surgery. The study found that 122 patients (30.42%) had postoperative complications. The types of complications included LEVT (56, 13.97%), cardiopulmonary complications (50, 12.47%), postoperative delirium (15, 3.74%), digestive system complications (6, 1.50%), urinary system complications (5, 1.25%), and incision infection (3, 0.75%). There were 17 patients (4.24%) with two or more complications (Table 1).
Table 1.
Basic characteristics of the patients included in the study
| Characteristics | Categories | Cases | Proportion |
|---|---|---|---|
| Gender | Female | 296 | 73.82% |
| Male | 105 | 26.18% | |
| Age | 65–74 | 255 | 63.59% |
| 75–84 | 116 | 28.93% | |
| ≥ 85 | 30 | 7.48% | |
| Surgical joint | Hip | 222 | 55.36% |
| Knee | 179 | 44.64% | |
| Surgery time limit | Emergency | 129 | 32.17% |
| Elective | 274 | 67.83% | |
| Incidence of Complications | Postoperative complications | 122 | 30.42% |
| LEVT | 56 | 13.97% | |
| Cardiopulmonary complications | 50 | 12.47% | |
| Postoperative delirium | 15 | 3.74% | |
| Digestive system complications | 6 | 1.50% | |
| Urinary system complications | 5 | 1.25% | |
| Incision infection | 3 | 0.75% | |
| Two or more complications | 17 | 4.24% |
Results of univariate statistical analysis of complications
The mean age of the 122 patients (93 females, 29 males) with complications was 75 ± 7.78 years, and the mean age of the 279 patients (203 females and 76 males) without complications was 72.39 ± 6.25 years. Univariate analysis revealed that age, BMI, hypertension, and anesthesia methods were significantly different in elderly patients with complications after hip or knee replacement surgery (P < 0.05) (Table 2).
Table 2.
Univariate analysis of related factors between patients with and without complications
| Risk Factors | Complications | No complications | OR | 95% CI | P | |
|---|---|---|---|---|---|---|
| (n = 122) | (n = 279) | Lower | Upper | |||
| Gender | 0.833 | 0.509 | 1.364 | 0.467 | ||
| Male | 29 | 76 | ||||
| Female | 93 | 203 | ||||
| Age | 75 ± 7.78 | 72.39 ± 6.25 | 1.033 | 4.179 | 0.001 | |
| BMI | 1.617 | 1.03 | 2.538 | 0.036 | ||
| 18.5–27.9 | 76 | 203 | ||||
| <18.4, ≥ 28 | 46 | 76 | ||||
| Smoking | 0.934 | 0.482 | 1.811 | 0.84 | ||
| Yes | 14 | 34 | ||||
| No | 108 | 245 | ||||
| Alcohol abuse | 0.748 | 0.309 | 1.809 | 0.518 | ||
| Yes | 7 | 21 | ||||
| No | 115 | 258 | ||||
| Diabetes | 0.955 | 0.584 | 1.563 | 0.856 | ||
| Yes | 30 | 71 | ||||
| No | 92 | 208 | ||||
| Hypertension | 1.635 | 1.039 | 2.573 | 0.033 | ||
| Yes | 85 | 163 | ||||
| No | 37 | 116 | ||||
| Types of disease | 1.365 | 0.891 | 2.091 | 0.152 | ||
| Fracture | 65 | 127 | ||||
| Nonfracture | 57 | 152 | ||||
| Surgery time limit | 1.466 | 0.94 | 2.288 | 0.091 | ||
| Emergency | 47 | 82 | ||||
| Elective | 77 | 197 | ||||
| Surgical joint | 1.18 | 0.768 | 1.814 | 0.45 | ||
| Hip | 71 | 151 | ||||
| Knee | 51 | 128 | ||||
| Type of surgery | 0.654 | 0.426 | 1.003 | 0.051 | ||
| Total joint replacement | 54 | 153 | ||||
| Partial joint replacement | 68 | 126 | ||||
| LOS | 3.70 ± 2.41 | 3.98 ± 3.23 | -0.926 | 0.356 | 0.382 | |
| VAS pain score | 0.699 | 0.449 | 1.088 | 0.112 | ||
| ≤ 4 | 74 | 192 | ||||
| ≥ 5 | 48 | 87 | ||||
| Anesthesia | 0.031 | |||||
| Spinal anesthesia | 78 | 181 | ||||
| General anesthesia | 27 | 37 | ||||
| Combined anesthesia | 17 | 61 | ||||
| Blood transfusion | 1.589 | 0.983 | 2.568 | 0.058 | ||
| Yes | 37 | 60 | ||||
| No | 85 | 219 | ||||
| ASA grade | 0.675 | 0.432 | 1.056 | 0.084 | ||
| I-II | 40 | 117 | ||||
| IV-III | 82 | 162 | ||||
| Start time of surgery | 0.785 | 0.505 | 1.221 | 0.283 | ||
| 8:00–14:00 | 75 | 187 | ||||
| 14:00–24:00 | 47 | 92 | ||||
| End time of surgery | 0.814 | 0.526 | 1.259 | 0.354 | ||
| 8:00–14:00 | 46 | 119 | ||||
| 14:00–24:00 | 76 | 160 | ||||
| Duration of stay in the operating room(minutes) | 250.69 ± 88.53 | 256.73 ± 114.27 | -28.900 | 16.814 | 0.604 | |
| Duration of anesthesia (minutes) | 233.03 ± 87.88 | 238.64 ± 113.28 | -28.279 | 17.054 | 0.627 | |
| Duration of surgery (minutes) | 139.55 ± 78.34 | 140.07 ± 63.91 | -15.159 | 14.121 | 0.944 | |
OR: odds ratio, CI: confidence interval
Results of unconditional binomial logistic regression analysis of complications
The risk factors that were statistically significant in univariate analysis and the significant factors considered by clinical experts (ASA grade, blood transfusion, and duration of surgery) were included in the unconditional binomial logistic regression analysis. The results revealed that age, BMI, and hypertension were independent risk factors for complications after hip or knee replacement surgery in elderly patients (P < 0.05) (Table 3).
Table 3.
Unconditional binary logistic regression analysis of risk factors
| Type | Risk Factors | β | Standardized error | Wald | P-value | OR | 95% CI | |
|---|---|---|---|---|---|---|---|---|
| Lower | Upper | |||||||
| Postoperative complications | Age | 0.637 | 0.171 | 13.841 | 0 | 1.891 | 1.352 | 2.644 |
| BMI | 0.568 | 0.237 | 5.723 | 0.017 | 1.764 | 1.108 | 2.809 | |
| Hypertension | 0.477 | 0.237 | 4.038 | 0.044 | 1.611 | 1.012 | 2.566 | |
| Constant | -2.829 | 0.479 | 34.918 | 0 | 0.059 | |||
| LEVT | Hypertension | 0.994 | 0.35 | 8.072 | 0.004 | 2.702 | 1.361 | 5.365 |
| Surgical joint | 0.729 | 0.302 | 5.829 | 0.016 | 2.072 | 1.147 | 3.744 | |
| VAS pain score | 0.911 | 0.301 | 9.161 | 0.002 | 2.488 | 1.379 | 4.489 | |
| Constant | -4.88 | 0.773 | 39.897 | 0 | 0.008 | |||
| Cardiopulmonary complications | Age | 0.834 | 0.216 | 14.865 | 0 | 2.302 | 1.507 | 3.517 |
| BMI | 0.688 | 0.319 | 4.638 | 0.031 | 1.99 | 1.064 | 3.721 | |
| Constant | -4.182 | 0.627 | 44.477 | 0 | 0.015 | |||
| Postoperative delirium | Age | 0.866 | 0.368 | 5.533 | 0.019 | 2.378 | 1.155 | 4.893 |
| ASA grade | 1.771 | 1.07 | 2.738 | 0.098 | 5.879 | 0.721 | 47.91 | |
| Constant | -7.906 | 2.042 | 14.985 | 0 | 0 | |||
| Two or more complications | Age | 1.353 | 0.344 | 15.504 | 0 | 3.869 | 1.973 | 7.588 |
| DM | 1.485 | 0.527 | 7.954 | 0.005 | 4.415 | 1.573 | 12.393 | |
| Constant | -5.992 | 0.81 | 54.675 | 0 | 0.002 | |||
The AUC was 0.639 (95% CI: 0.58–0.698; Fig. 2; Table 4), indicating that the predictive effect of the logistic regression model was general.
Fig. 2.
AUC of the predicted meaningful and risk factors for complications
Table 4.
AUC of the predicted meaningful and risk factors
| Complications | Area | Std. Errora | Asymptotic Sig.b | Asymptotic 95% Confidence Interval | |
|---|---|---|---|---|---|
| Lower Bound | Upper Bound | ||||
| Postoperative complications | 0.639 | 0.03 | 0 | 0.580 | 0.698 |
| LEVT | 0.681 | 0.037 | 0 | 0.609 | 0.753 |
| Cardiopulmonary complications | 0.658 | 0.044 | 0 | 0.571 | 0.745 |
| Postoperative delirium | 0.77 | 0.049 | 0 | 0.675 | 0.865 |
| Two or more complications | 0.77 | 0.063 | 0 | 0.647 | 0.893 |
Results of univariate statistical analysis of LEVT
The mean age of the 56 patients (45 females, 11 males) with LEVT was 72.66 ± 6.97 years, and the mean age of the 345 patients (251 females, 94 males) without LEVT was 73.27 ± 6.83 years. Among the 56 patients with LEVT, 16 patients were diagnosed deep vein thrombosis (DVT), 39 patients were diagnosed muscular vein thrombosis, 1 patients were diagnosed DVT and muscular vein thrombosis. Univariate analysis revealed that hypertension, surgical joints, and VAS pain scores were significantly different in elderly patients with or without LEVT after hip or knee replacement surgery (P < 0.05) (Table 5).
Table 5.
Univariate analysis of related factors between patients with and without LEVT
| Risk Factors | Complications | No complications | OR | 95% CI | P | |
|---|---|---|---|---|---|---|
| (n = 56) | (n = 345) | Lower | Upper | |||
| Gender | 0.653 | 0.324 | 1.315 | 0.23 | ||
| Male | 11 | 94 | ||||
| Female | 45 | 251 | ||||
| Age | 72.66 ± 6.97 | 73.27 ± 6.83 | -2.55 | 1.33 | 0.536 | |
| BMI | 1.585 | 0.884 | 2.844 | 0.12 | ||
| 18.5–27.9 | 22 | 100 | ||||
| <18.4, ≥ 28 | 34 | 245 | ||||
| Hypertension | 2.534 | 1.292 | 4.97 | 0.005 | ||
| Yes | 44 | 204 | ||||
| No | 12 | 141 | ||||
| Surgical joint | 0.557 | 0.315 | 0.985 | 0.042 | ||
| Hip | 24 | 198 | ||||
| Knee | 32 | 147 | ||||
| VAS pain score | 0.45 | 0.254 | 0.796 | 0.005 | ||
| ≤ 4 | 28 | 238 | ||||
| ≥ 5 | 28 | 107 | ||||
| Types of disease | 0.726 | 0.409 | 1.287 | 0.271 | ||
| Fracture | 23 | 169 | ||||
| Non-fracture | 33 | 176 | ||||
| ASA grade | 1.195 | 0.675 | 2.118 | 0.54 | ||
| I-II | 24 | 133 | ||||
| IV-III | 32 | 212 | ||||
Results of unconditional binomial logistic regression analysis of LEVT
The risk factors that were statistically significant in univariate analysis and the significant factors considered by clinical experts (ASA grade, type of disease) were included in the unconditional binomial logistic regression analysis. The results revealed that hypertension, surgical joint type, and VAS pain score were independent risk factors for LEVT after hip or knee replacement surgery in elderly patients (P < 0.05) (Table 3).
The AUC was 0.681 (95% CI: 0.609–0.753; Fig. 3; Table 4), indicating that the predictive effect of the logistic regression model was general.
Fig. 3.
AUC of the predicted meaningful and risk factors for LEVT
Results of univariate statistical analysis of cardiopulmonary complications
The mean age of the 50 patients (36 females, 14 males) with cardiopulmonary complications was 76.82 ± 8.13 years, and the mean age of the 351 patients (260 females, 91 males) without cardiopulmonary complications was 72.67 ± 6.50 years. Univariate analysis revealed that age, type of disease, surgical joint, type of surgery, anesthesia, ASA grade, and blood transfusion were statistically significant in elderly patients with or without cardiopulmonary complications after hip or knee replacement (P < 0.05) (Table 6).
Table 6.
Univariate analysis of related factors between patients with and without cardiopulmonary complications
| Risk Factors | Complications | No complications | OR | 95% CI | P | |
|---|---|---|---|---|---|---|
| (n = 50) | (n = 351) | Lower | Upper | |||
| Gender | 1.111 | 0.573 | 2.154 | 0.755 | ||
| Male | 14 | 91 | ||||
| Female | 36 | 260 | ||||
| Age | 76.82 ± 8.13 | 72.67 ± 6.50 | 1.747 | 6.554 | 0.001 | |
| BMI | 1.585 | 0.884 | 2.844 | 0.12 | ||
| 18.5–27.9 | 22 | 100 | ||||
| <18.4, ≥ 28 | 34 | 245 | ||||
| Types of disease | 1.925 | 1.048 | 3.538 | 0.033 | ||
| Fracture | 31 | 161 | ||||
| Non-fracture | 19 | 190 | ||||
| Surgical joint | 2.281 | 1.189 | 4.378 | 0.011 | ||
| Hip | 36 | 186 | ||||
| Knee | 14 | 165 | ||||
| Type of surgery | 0.531 | 0.289 | 0.976 | 0.039 | ||
| Total joint replacement | 19 | 188 | ||||
| Partial joint replacement | 31 | 163 | ||||
| Anesthesia | 0.000 | |||||
| Spinal anesthesia | 28 | 231 | ||||
| General anesthesia | 18 | 46 | ||||
| Combined anesthesia | 4 | 74 | ||||
| Blood transfusion | 2.145 | 1.149 | 4.004 | 0.015 | ||
| Yes | 19 | 78 | ||||
| No | 31 | 273 | ||||
| ASA grade | 0.505 | 0.259 | 0.984 | 0.042 | ||
| I-II | 13 | 144 | ||||
| IV-III | 37 | 207 | ||||
| Duration of surgery (minutes) | 132.64 ± 82.35 | 140.95 ± 66.40 | -28.678 | 12.066 | 0.423 | |
Results of unconditional binomial logistic regression analysis of cardiopulmonary complications
The risk factors that were statistically significant in univariate analysis and the significant factors considered by clinical experts (BMI, duration of surgery) were included in the unconditional binomial logistic regression analysis. The results revealed that age and BMI were independent risk factors for cardiopulmonary complications after hip or knee replacement surgery in elderly patients (P < 0.05) (Table 3).
The AUC was 0.658 (95% CI: 0.571–0.745; Fig. 4; Table 4), indicating that the predictive effect of the logistic regression model was general.
Fig. 4.
AUC of the predicted meaningful and risk factors for cardiopulmonary complications
Results of univariate statistical analysis of postoperative delirium
The average age of the 15 patients (12 females, 3 males) who developed postoperative delirium was 78.27 ± 6.33 years, and the average age of the 386 patients (284 females, 102 males) who did not develop postoperative delirium was 72.99 ± 6.80 years. Univariate analysis revealed that age, type of disease, surgical joint, type of surgery, and ASA grade were significantly different between elderly patients with and without postoperative delirium after hip or knee replacement (P < 0.05) (Table 7).
Table 7.
Univariate analysis of related factors between patients with and without postoperative delirium
| Risk Factors | Complications | No complications | OR | 95% CI | P | |
|---|---|---|---|---|---|---|
| (n = 15) | (n = 386) | Lower | Upper | |||
| Gender | ||||||
| Male | 3 | 102 | 0.696 | 0.193 | 2.517 | 0.798 |
| Female | 12 | 284 | ||||
| Age | 78.27 ± 6.33 | 72.99 ± 6.80 | 1.767 | 8.787 | 0.003 | |
| BMI | 1.591 | 0.553 | 4.572 | 0.561 | ||
| 18.5–27.9 | 6 | 114 | ||||
| <18.4, ≥ 28 | 9 | 272 | ||||
| Types of disease | 4.578 | 1.272 | 16.479 | 0.011 | ||
| Fracture | 12 | 180 | ||||
| Non-fracture | 3 | 206 | ||||
| Surgical joint | 3.352 | 0.931 | 12.068 | 0.05 | ||
| Hip | 12 | 210 | ||||
| Knee | 3 | 176 | ||||
| Type of surgery | 0.223 | 0.062 | 0.803 | 0.012 | ||
| Total joint replacement | 3 | 204 | ||||
| Partial joint replacement | 12 | 182 | ||||
| ASA grade | 0.104 | 0.014 | 0.8 | 0.008 | ||
| I-II | 1 | 157 | ||||
| IV-III | 14 | 229 | ||||
| Duration of surgery (minutes) | 125 ± 87.09 | 140 ± 67.78 | -50.954 | 19.974 | 0.391 | |
Results of unconditional binomial logistic regression analysis of postoperative delirium
The risk factors that were statistically significant in univariate analysis and the significant factors considered by clinical experts (BMI, duration of surgery) were included in the unconditional binomial logistic regression analysis. The results revealed that age and ASA grade were independent risk factors for postoperative delirium after hip or knee replacement surgery in elderly patients (P < 0.05) (Table 3).
The AUC was 0.77 (95% CI: 0.675–0.865; Fig. 5; Table 4), indicating that the predictive effect of the logistic regression model was reliable.
Fig. 5.
AUC of the predicted meaningful and risk factors for postoperative delirium
Results of univariate statistical analysis of two or more complications
The average age of the 17 patients (16 females, 1 male) with two or more complications was 77.88 ± 7.71 years, and the average age of the other 384 patients (280 females, 104 males) was 72.98 ± 6.74 years. Univariate analysis revealed that age, diabetes status, type of disease, type of surgery, blood transfusion, and ASA grade were significantly different in elderly patients with or without two or more complications after hip or knee replacement surgery (P < 0.05) (Table 8).
Table 8.
Univariate analysis of related factors between patients with and without two or more complications
| Risk Factors | Complications | No complications | OR | 95% CI | P | |
|---|---|---|---|---|---|---|
| (n = 17) | (n = 384) | Lower | Upper | |||
| Gender | 0.168 | 0.022 | 1.285 | 0.096 | ||
| Male | 1 | 104 | ||||
| Female | 16 | 280 | ||||
| Age | 77.88 ± 7.71 | 72.98 ± 6.74 | 1.597 | 8.210 | 0.004 | |
| BMI | 0.975 | 0.336 | 2.83 | 0.962 | ||
| 18.5–27.9 | 5 | 115 | ||||
| <18.4, ≥ 28 | 12 | 269 | ||||
| Diabetes | 3.571 | 1.339 | 9.521 | 0.016 | ||
| Yes | 9 | 92 | ||||
| No | 8 | 292 | ||||
| Types of disease | 3.722 | 1.192 | 11.62 | 0.016 | ||
| Fracture | 13 | 179 | ||||
| Non-fracture | 4 | 205 | ||||
| Type of surgery | 0.274 | 0.088 | 0.856 | 0.018 | ||
| Total joint replacement | 4 | 203 | ||||
| Partial joint replacement | 13 | 181 | ||||
| Blood transfusion | 2.946 | 1.104 | 7.862 | 0.05 | ||
| Yes | 8 | 89 | ||||
| No | 9 | 295 | ||||
| ASA grade | 0.197 | 0.044 | 0.874 | 0.018 | ||
| I-II | 2 | 155 | ||||
| IV-III | 15 | 229 | ||||
| Duration of surgery (minutes) | 118.65 ± 80.96 | 140.85 ± 67.89 | -55.563 | 11.154 | 0.191 | |
Results of unconditional binomial logistic regression analysis of two or more complications
The risk factors that were statistically significant in univariate analysis and the significant factors considered by clinical experts (BMI, duration of surgery) were included in the unconditional binomial logistic regression analysis. The results revealed that age and diabetes were independent risk factors for two or more complications after hip and knee replacement surgery in elderly patients (P < 0.05) (Table 3).
The AUC was 0.77 (95% CI: 0.647–0.893; Fig. 6; Table 4), indicating that the predictive effect of the logistic regression model was reliable.
Fig. 6.
AUC of the predicted meaningful and risk factors for two or more complications
Discussion
With the increasing demand for improved mobility and quality of life, as well as the continuous development of surgical techniques and artificial joint materials, the number of hip and knee replacement surgeries has significantly increased each year [15, 16]. Maradit et al. [5] predicted that an estimated 11 million people would undergo total hip or knee replacement by 2030. After years of advancement, the effectiveness and benefits of joint replacement surgery have been widely recognized. However, with such a large number of procedures being performed, postoperative complications remain an important concern. This is especially true for elderly patients, as complications can significantly affect both their quality of life and, in severe cases, their survival.
This study retrospectively analyzed complications in 401 elderly patients who were hospitalized for hip or knee surgery. It was found that elderly patients had a high probability of experiencing complications after hip or knee replacement surgery, with an overall incidence of 30.42%. Among them, the incidence of LEVT was 13.97%, cardiopulmonary complications 12.47%, postoperative delirium 3.74%, and two or more complications 4.24%. Age, BMI, and hypertension were identified as independent risk factors for complications, with an AUC of 0.639, indicating a general predictive performance of the logistic regression model. Hypertension and surgical joint type were independent risk factors for LEVT, with an AUC of 0.681. Age and BMI were independent risk factors for cardiopulmonary complications, with an AUC of 0.658. Age and ASA grade were found to be independent risk factors for postoperative delirium, with an AUC of 0.77, indicating reliable predictive ability. Age and diabetes mellitus (DM) were independent risk factors for two or more complications, with an AUC of 0.77, also suggesting a reliable prediction model. Overall, age, BMI, and hypertension were independent risk factors for multiple complications.
The risk of surgical complications increases with age. We found that for each 10-year increase in age, the odds ratio (OR) for complications after hip or knee arthroplasty was 1.90; for cardiopulmonary complications, 2.30; for postoperative delirium, 2.38; and for two or more complications, 3.87. These results are consistent with previous findings. For example, Basilico et al. [17] found that advanced age is a risk factor for cardiac complications following total joint replacement surgery, and Canet et al. [18] reported that the risk of postoperative pulmonary complications increases by 5.6 times in patients over 80 years of age. Furthermore, studies have shown that advanced age not only raises the risk of perioperative cardiovascular complications but also increases the risk of death within 30 days after surgery [19, 20].
Obesity is a well-known risk factor for the development of osteoarthritis and the subsequent need for joint replacement [21, 22], and it also increases the risk of complications following total joint replacement surgery [23]. Therefore, orthopedic surgeons increasingly recommend weight loss, which has been shown to reduce pain, disability, and the need for joint replacement, particularly in patients with knee osteoarthritis [21]. Additionally, hypertensive patients face increased risks of complications after various surgeries, experience longer hospital stays, and have higher mortality rates compared to non-hypertensive patients [24–26]. A study of 46,322 patients undergoing TKA or THA found that being over 80 years old and requiring antihypertensive medication were the most significant risk factors for postoperative cardiac complications [27]. Other studies have also confirmed that elderly hypertensive patients undergoing joint replacement surgery are at greater risk for postoperative complications [28, 29]. Theoretically, the severity of hypertension may influence the incidence of complications. However, due to limited data, this study did not analyze the relationship between hypertension grading and postoperative complications. Future studies should explore this in more detail.
Diabetes increases the risk of complications following surgical procedures, including THA and TKA, and the prevalence of diabetes among patients undergoing these procedures is approximately 8–20% [30, 31]. High and unstable blood glucose levels during the perioperative period not only prolong hospitalization but also increase the risk of surgical complications and mortality [32–34]. Therefore, for elderly diabetic patients undergoing hip or knee replacement, monitoring and maintaining blood glucose levels within the normal range during the perioperative period is crucial to minimize fluctuations and improve outcomes.
Several studies have reported inconsistent rates of LEVT following hip and knee arthroplasty. The incidence of LEVT after hip arthroplasty ranges from 8.9 to 10.5% [35, 36], while after knee arthroplasty it is approximately 25.6% [36]. However, another study on patients who did not receive thromboprophylaxis [37], reported higher rates, reaching 57.6% in TKR patients and 33.5% in THR patients. In addition, studies have confirmed that hypertension is an independent risk factor for deep vein thrombosis (DVT) after joint replacement [38], consistent with our findings.
Delirium is particularly common among elderly patients following major surgery, with an incidence of approximately 44% [39]. The incidence of delirium after joint replacement has been reported to be 28% in patients undergoing hip replacement [40, 41], and between 4% and 41% in those undergoing bilateral knee replacement [42]. Jain et al. [43] suggested that pre-anesthesia hypotension in elderly patients is a significant contributor to postoperative delirium. They noted that younger patients could tolerate lower blood pressure without significant cognitive impact. Their study identified age ≥ 74 years, ASA grade ≥ 3, and mean arterial pressure (MAP) < 90 mmHg as risk factors for delirium following joint replacement surgery—findings consistent with ours.
The case data in this study were collected retrospectively in a general hospital, which inevitably introduces selection bias. Additionally, the sample size was relatively small. Future multicenter clinical studies would help generate more stable and generalizable results. Although some preoperative laboratory indicators were collected during this study, including those related to nutritional status (e.g., hemoglobin, high-density lipoprotein), they were not statistically significant and thus not included as potential risk factors. This may be due to the inaccuracy in recording the timing of sample collection and reporting. This represents another limitation of the study. Despite some limitations, we statistically analyzed 6 years of data and the identified risk factors for general complications after hip or knee arthroplasty in elderly patients. With the continuous development of surgical techniques, advanced age is no longer a contraindication for joint replacement. In the current situation of increasingly serious aging society, solving the hip and knee joint problems of elderly patients is not only a key measure to ensure their quality of life, but also can reduce the social burden and family burden to a certain extent. For elderly patients with hip or knee replacements to study the risk factors of complications after the surgery, is not only an important supplement to the existing literature research, but also can help clinical medical personnel ready to targeted prevention treatment, thereby reducing elderly patients with hip and knee arthroplasties risk of general complications after the surgery.
Conclusions
Clinical attention should be given to the risk factors for complications following hip and knee replacement surgery. Proper preoperative evaluation and perioperative management in elderly patients are essential to reduce the risk of complications as much as possible. This study identified independent risk factors for complications after hip and knee replacement surgery in elderly patients and analyzed and evaluated independent risk factors for postoperative lower limb vein thrombosis, cardiopulmonary complications, postoperative delirium, and the occurrence of two or more complications. However, only two types of complications were reliably predicted by the logistic regression model. Nevertheless, this study provides a valuable reference for the clinical prevention and management of postoperative complications in elderly patients undergoing hip and knee replacement surgery.
Acknowledgements
The authors would like to thank all the staff of the participating departments.
Author contributions
H.Z. : Conceptualization, Investigation, Methodology, Formal analysis, Writing – original draft.J.C. : Investigation, Visualization, Writing – review and editing.J.C. : Supervision, Validation, Writing – review and editing.X. N. : Project administration, Resources, Writing – review and editing.
Funding
This study received no direct funding from any third-party donor or funding institution in the public, commercial, or non-profit sectors.
Data availability
The datasets generated during this current study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
Written informed consent was waived by the Institutional Review Board of Hebei General Hospital as the study was retrospective in nature (2024-LW-0237). All experimental protocols were approved by the same Institutional Review Board of Hebei General Hospital and followed the Declaration of Helsinki.
Consent for publication
No application.
Competing interests
The authors declare no competing interests.
Authors’contributions
Huaxing Zhang(H.Z.): Conceptualization, Investigation, Methodology, Formal analysis, Writing-original draft.
Jingjing Cao(J.C.) : Investigation, Visualization, Writing-review and editing.
Jia Chen(J.C.): Supervision, Validation, Writing- review and editing.
Xiaoran Ning(X.N.).: Project administration, Resources, Writing-review and editing.
All authors have read andapproved the final manuscript.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Kurtz S, Ong K, Fau - Lau E, Lau E, Fau - Mowat F, Mowat F, Fau - Halpern M, Halpern M. Projections of primary and revision hip and knee arthroplasty in the united States from 2005 to 2030. [DOI] [PubMed]
- 2.Sanders TL, Maradit Kremers H, Schleck CD, Larson DR, Berry DJ. Subsequent total joint arthroplasty after primary total knee or hip arthroplasty. J Bone Joint Surg. 2017;99:396–401. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Matsuoka H, Nanmo H, Nojiri S, Nagao M, Nishizaki Y. Projected numbers of knee and hip arthroplasties up to the year 2030 in Japan. [DOI] [PubMed]
- 4.Smith LK, Dures E, Beswick AD. Systematic review of the clinical effectiveness for long-term follow-up of total hip arthroplasty. Orthop Res Reviews. 2019;11:69–78.<\/p> [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Maradit Kremers H, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, Jiranek WA, Berry DJ. Prevalence of total hip and knee replacement in the united States. J Bone Joint Surgery-American Volume. 2015;97:1386–97. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Talmo CT, Robbins CE, Bono JV. Total joint replacement in the elderly patient. Clin Geriatr Med. 2010;26:517–29. [DOI] [PubMed] [Google Scholar]
- 7.Abdelaal MS, Restrepo C, Sharkey PF. Global perspectives on arthroplasty of hip and knee joints. Orthop Clin North Am. 2020;51:169–76. [DOI] [PubMed] [Google Scholar]
- 8.Kubeš R, Král A, Stollin M, Bobelyak M. [Effects of total hip or knee arthroplasty on median survival in patients aged 80 years and older]. [DOI] [PubMed]
- 9.Badge HA-OX, Churches TA-O, Naylor JM, Xuan W, Armstrong E, Gray L, Fletcher J, Gosbell I, Lin CA-O, Harris IA. Non-compliance with clinical guidelines increases the risk of complications after primary total hip and knee joint replacement surgery. [DOI] [PMC free article] [PubMed]
- 10.Oliveira BA-O, Costa VA-O, Gama IA-O, Beskow MA-O, Santos EA-O. Diagnosis and prevention of periprosthetic joint infections by Staphylococcus aureus after hip fracture: A Systematic Review of the Literature. [DOI] [PMC free article] [PubMed]
- 11.Dang KA-O, Badge H, Harris IA. Validity of patient-reported complications after total hip and knee arthroplasty. [DOI] [PubMed]
- 12.Ferguson RJ, Palmer AJR, Taylor A, Porter ML, Malchau H, Glyn-Jones S. Hip replacement. Lancet. 2018;392:1662–71. [DOI] [PubMed] [Google Scholar]
- 13.Price AJ, Alvand A, Troelsen A, Katz JN, Hooper G, Gray A, Carr A, Beard D. Knee replacement. Lancet. 2018;392:1672–82. [DOI] [PubMed] [Google Scholar]
- 14.Rosner B, Tworoger S. Correcting AUC for measurement error. J Biometrics Biostatistics 2015, 06. [DOI] [PMC free article] [PubMed]
- 15.Inacio MCS, Paxton EW, Graves SE, Namba RS, Nemes S. Projected increase in total knee arthroplasty in the united States - an alternative projection model. [DOI] [PubMed]
- 16.Culliford D, Maskell J, Judge A, Cooper C, Prieto-Alhambra D, Arden NK. Future projections of total hip and knee arthroplasty in the UK: results from the UK clinical practice research datalink. [DOI] [PubMed]
- 17.Basilico FC, Sweeney G, Losina E, Gaydos J, Skoniecki D, Wright EA, Katz JN. Risk factors for cardiovascular complications following total joint replacement surgery. Arthr Rhuem. 2008;58:1915–20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Canet J, Gallart L, Fau - Gomar C, Gomar C, Fau - Paluzie G, Paluzie G, Fau - Vallès J, Vallès J, Fau - Castillo J, Castillo J, Fau - Sabaté S, Sabaté S Fau - Mazo V, Mazo V Fau - Briones Z, Briones Z Fau - Sanchis, Sanchis J. J: Prediction of postoperative pulmonary complications in a population-based surgical cohort.
- 19.Hansen PW, Gislason GH, Jørgensen ME, Køber L, Jensen PF, Torp-Pedersen C, Andersson C. Influence of age on perioperative major adverse cardiovascular events and mortality risks in elective non-cardiac surgery. Eur J Intern Med. 2016;35:55–9. [DOI] [PubMed] [Google Scholar]
- 20.Banco D, Dodson JA, Berger JS, Smilowitz NR. Perioperative cardiovascular outcomes among older adults undergoing in-hospital noncardiac surgery. J Am Geriatr Soc. 2021;69:2821–30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Wall CA-O, Lee SA-O, Ma Y, de Steiger RA-O, Vertullo CA-O. Kondalsamy-Chennakesavan SA-OX: do patients with osteoarthritis lose weight prior to elective joint replacement?. [DOI] [PubMed]
- 22.Wendelboe AM, Hegmann Kt Fau - Biggs JJ. Biggs Jj Fau - Cox CM, Cox cm Fau - portmann AJ, portmann Aj Fau - Gildea JH, Gildea Jh Fau - Gren LH, Gren Lh Fau - Lyon JL, Lyon JL: relationships between body mass indices and surgical replacements of knee and hip joints. [DOI] [PubMed]
- 23.Carroll JA-O, Young Jr. Auid- Orcid: --- Fau - Mori BV, Mori Bv Auid- Orcid: --- Fau - Gheewala R, Gheewala R Auid- Orcid: --- Fau - Lakra A, Lakra A Auid- Orcid: --- Fau - DiCaprio MR, DiCaprio MA-O: Total Hip and Knee Arthroplasty Surgery in the Morbidly Obese Patient: A Critical Analysis Review. LID - e22.00177 [doi]. [DOI] [PubMed]
- 24.Gupta P, Quan T, Patel CJ, Gu A, Campbell JC. Extended length of stay and postoperative complications in octogenarians with hypertension following revision total knee arthroplasty. [DOI] [PMC free article] [PubMed]
- 25.Kocher NJ, Canes D, Bensalah K, Roupret M, Lallas C, Margulis V, Shariat S, Colin P, Matin S, Tracy C et al. Incidence and preoperative predictors for major complications following radical nephroureterectomy. [DOI] [PMC free article] [PubMed]
- 26.Schurr P, Boeken U, Fau - Litmathe J, Litmathe J, Fau - Feindt P, Feindt P, Fau - Kurt M, Kurt M, Fau - Gams E, Gams E. Predictors of postoperative complications in octogenarians undergoing cardiac surgery. [DOI] [PubMed]
- 27.Belmont PJ Jr., Goodman GP, Kusnezov NA, Magee C, Bader JO, Waterman BR, Schoenfeld AJ. Postoperative myocardial infarction and cardiac arrest following primary total knee and hip arthroplasty: rates, risk factors, and time of occurrence. [DOI] [PubMed]
- 28.Schick CW, Koehler DM, Martin CT, Gao Y, Pugely AJ, Shah A, Adams BD. Risk factors for 30-day postoperative complications and mortality following open reduction internal fixation of distal radius fractures. [DOI] [PubMed]
- 29.Greenky MR, Wang W, Ponzio DY, Courtney PM. Total hip arthroplasty and the medicare Inpatient-Only list: an analysis of complications in medicare-Aged Patients Undergoing Outpatient Surgery. [DOI] [PubMed]
- 30.Ortved M, Petersen PB, Jørgensen CC, Kehlet H. Postoperative morbidity and mortality in diabetic patients after Fast-Track hip and knee arthroplasty: A prospective Follow-up cohort of 36,762 procedures. [DOI] [PubMed]
- 31.Berstock JR, Beswick AD, López-López JA, Whitehouse MR, Blom AW. Mortality after total knee arthroplasty: A systematic review of incidence, Temporal Trends, and Risk Factors. [DOI] [PubMed]
- 32.Shohat N, Restrepo C, Allierezaie A, Tarabichi M, Goel R, Parvizi J. Increased Postoperative Glucose Variability Is Associated with Adverse Outcomes Following Total Joint Arthroplasty. [DOI] [PubMed]
- 33.Chrastil J, Anderson MB, Stevens V, Anand R, Peters CL, Pelt CE. Is hemoglobin A1c or perioperative hyperglycemia predictive of periprosthetic joint infection or Death Following Primary Total Joint Arthroplasty?. [DOI] [PubMed]
- 34.Gallagher JM, Erich RA, Gattermeyer R, Beam KK. Postoperative hyperglycemia can be safely and effectively controlled in both diabetic and nondiabetic patients with use of a subcutaneous insulin protocol. [DOI] [PMC free article] [PubMed]
- 35.Venher I, Kostiv S, Khvalyboha D. Risk factors for venous thrombosis in patients with endoprosthetics of hip joints. J Educ Health Sport. 2021;11:875–85. [Google Scholar]
- 36.O’Reilly RF, Burgess Ia Fau -, Zicat B, Zicat B. The prevalence of venous thromboembolism after hip and knee replacement surgery. [DOI] [PubMed]
- 37.Cordell-Smith JA. Williams Sc Fau - Harper WM, Harper Wm Fau - Gregg PJ, Gregg PJ: lower limb arthroplasty complicated by deep venous thrombosis. Prevalence and subjective outcome. [PubMed]
- 38.Liu HA-OX, Peng YA-O. Analysis of risk factors for postoperative lower Extremity Deep Venous Thrombosis and its Treatment and Nursing. [DOI] [PMC free article] [PubMed]
- 39.Robinson TN, Raeburn Cd Fau - Tran ZV, Tran Zv Fau - Angles EM, Angles Em Fau - Brenner LA, Brenner La Fau - Moss M, Moss M. Postoperative delirium in the elderly: risk factors and outcomes. [DOI] [PubMed]
- 40.Rogers MP. Liang Mh Fau - Daltroy LH, Daltroy Lh Fau - Eaton H, Eaton H Fau - Peteet J, Peteet J Fau - Wright E, Wright E Fau - Albert M, Albert M: Delirium after elective orthopedic surgery: risk factors and natural history. [DOI] [PubMed]
- 41.Sampson EL, Raven Pr Fau - Ndhlovu PN, Ndhlovu Pn Fau -, Vallance A, Vallance A, Fau - Garlick N, Garlick N, Fau - Watts J, Watts J. Fau - Blanchard MR, Blanchard Mr Fau - Bruce A, Bruce A Fau - blizard R, blizard R Fau - Ritchie CW, Ritchie CW: A randomized, double-blind, placebo-controlled trial of donepezil hydrochloride (Aricept) for reducing the incidence of postoperative delirium after elective total hip replacement. [DOI] [PubMed]
- 42.Williams-Russo P, Urquhart Bl Fau - Sharrock NE, Sharrock Ne Fau - Charlson ME, Charlson ME. Post-operative delirium: predictors and prognosis in elderly orthopedic patients. [DOI] [PubMed]
- 43.Jain FA, Stern TA. Individual risk profiles for postoperative delirium after joint replacement surgery. [DOI] [PubMed]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated during this current study are available from the corresponding author upon reasonable request.