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Gastrointestinal Complications Warranting Invasive Interventions Following Total Joint Arthroplasty
The Journal of Arthroplasty xxx (2019) 1e5
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Gastrointestinal Complications Warranting Invasive Interventions Following Total Joint Arthroplasty Abidemi S. Adenikinju, MD *, James E. Feng, MD, Clementine A. Namba, MHS, Tyler A. Luthringer, MD, Claudette M. Lajam, MD Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 March 2019 Received in revised form 24 May 2019 Accepted 8 June 2019 Available online xxx
Background: Gastrointestinal (GI) complications following total joint arthroplasty (TJA) are uncommon but can be associated with substantial morbidity and mortality. The current literature on GI complications that warrant invasive procedures after TJA is lacking. This study reviews the incidence and outcomes of GI complications after TJA that went on to require invasive procedures. Methods: All TJA patients at our institution between January 2012 and May 2018 who had GI complications requiring an invasive procedure within 30 days of TJA were identified and retrospectively chart reviewed. Descriptive statistics were used to evaluate these patients. Results: Of 19,090 TJAs in a 6-year period, 34 patients (0.18%) required invasive procedures for GI complications within 30 days of the index surgery. Twenty-two (64%) of the required procedures were endoscopy for suspected GI bleeding. Within this cohort, aspirin was the most common thromboprophylaxis used (63.6% of patients) and smoking was more prevalent (9.1% current smokers) (P ¼ .28). Of the remaining 12 GI procedures required, 75% were exploratory laparotomies, 44.4% of which were performed for obstruction. Three (33.3%) of the exploratory laparotomy patients died during the study period. Conclusion: GI complications necessitating surgical intervention after TJA are rare. Suspected GI bleeding is the most common indication for intervention and is typically managed endoscopically. Other complications, such as GI obstruction, often require more extensive intervention and open procedures. Though rare, GI complications following TJA can lead to detrimental outcomes, significant patient morbidity, and occasionally mortality; therefore, a heightened awareness of these complications is warranted. © 2019 Elsevier Inc. All rights reserved.
Keywords: total joint arthroplasty complications total hip arthroplasty complications total knee arthroplasty complications gastrointestinal complications
Over the last century, total hip (THA) and total knee arthroplasties (TKA) have evolved into immensely successful procedures for relieving pain and restoring function in patients suffering from joint pathology. Over 1,000,000 hip and knee total joint arthroplasties (TJAs) are performed annually in the United States alone, and this number is expected to reach 4,000,000 by 2030 [1,2].
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 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 https://doi.org/10.1016/j.arth.2019.06.026. * Reprint requests: Abidemi S. Adenikinju, MD, NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003. https://doi.org/10.1016/j.arth.2019.06.026 0883-5403/© 2019 Elsevier Inc. All rights reserved.
Although TJA is generally safe, systemic complications secondary to the insult of surgery (unrelated to the prostheses) can and do occur [3,4]. A few risk factors for such complications include older age, higher body mass index (BMI), pre-existing medical comorbidities, and longer operative time [3,5,6]. Gastrointestinal (GI) complications following TJA are uncommon but can be associated with substantial morbidity and mortality. Reported complications include acute colonic pseudoobstruction (ACPO), GI bleeding (GIB), pancreatitis, diverticulitis, and intestinal ischemia [4,7e20]. The incidence of each complication varies by series, with ACPO and GIB occurring in up to 4% [4,9,14e16] and 4.5% [4,11,14,21] of TJA patients, respectively. These complications typically occur in the acute postoperative period, within 1 to 2 weeks after surgery [8,11,14,15,20]. Although managed conservatively when possible, severe cases may warrant surgical intervention, including endoscopy, laparoscopy, and laparotomy
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with possible gastric or bowel resection [4,10,11,15,22]. These secondary invasive procedures increase patient length of stay, risk of further complications, overall patient morbidity and mortality, as well as healthcare costs [23]. GI complications requiring secondary procedures after TJA are rarely addressed in the current literature. Given that TJA complications and patient outcomes are used to assess hospital performance and affect new payment models, a greater understanding of the incidence, risk factors, and possible prevention of these complications is necessary [24e26]. This study evaluates the incidence and outcomes of GI complications requiring invasive procedures within 30 days of THA and TKA. Materials and Methods This study is a retrospective observational quality study conducted at a single tertiary academic care center with a dedicated, high-volume orthopedic hospital. All patients who underwent unilateral or bilateral primary THA or TKA and had a second procedure within 30 days of the index TJA between January 2012 and May 2018 were included. Subjects were identified by our electronic medical record database. Patients with secondary surgical procedures other than colonoscopy, sigmoidoscopy, laparotomy, laparoscopy, or esophagogastroduodenoscopy were excluded. Patients who had more than one of the same GI procedure for the same complication were only included once. Demographics including patient age, gender, BMI, procedure type, race, smoking status, insurance type, comorbidities, and American Society of Anesthesiologists score were collected for all subjects. Perioperative variables from the index TJA were also collected, including thromboprophylaxis, surgical time, and discharge disposition. All queried data were retrieved using Microsoft SQL Server Management Studio 2017 (Richmond, WA). Statistical analysis was performed using MATLAB 2018a (MathWorks, Natick, MA). Demographics and surgical variables were summarized by standard descriptive summaries (eg, means and standard deviations for continuous variables).
Table 1 Patient Demographics. Characteristics
N ¼ 34 (%)
Age Gender Female Male BMI (kg/m2) ASA score 1 2 3 4 Unknown Smoking status Current smoker Former smoker Never smoker Unknown Race African American Asian Other/unknown White Procedure THA TKA Bilateral THA Bilateral TKA Thromboprophylaxis Aspirin Enoxaparin Warfarin Unknown
69 ± 10.2 18 (53.9) 16 (47.1) 30.5 ± 6.9 0 8 9 3 14
(23.5) (26.5) (23.5) (41.2)
2 11 17 4
(5.9) (28.9) (50) (11.8)
6 1 6 21
(17.6) (3) (17.6) (61)
14 16 1 3
(41.2) (47.1) (3) (8.8)
21 6 6 1
(64.7) (14.7) (17.6) (3)
ASA, American Society of Anesthesiologists; BMI, body mass index; THA, total hip arthroplasty; TKA, total knee arthroplasty.
cholecystectomy. Finally, one esophagogastroduodenoscopy was performed for variceal screening prior to transesophageal echocardiogram that was needed to evaluate for endocarditis. Discussion
Results In total, 19,090 TJAs in a 6-year period were examined. Thirtyfour patients (0.18%) required secondary invasive procedures for GI complications within 30 days of their index TJA. The mean age of patients requiring secondary procedures was 69 ± 10.2 years, with an average BMI of 30.5 ± 6.9 (Table 1). There was no gender predilection among those requiring secondary GI procedures (Table 1). Of the 34 patients who required GI intervention, 22 (64.7%) underwent low-risk GI procedures (endoscopy) for suspected acute GIB. Aspirin (63.6%) was the most common thromboprophylaxis agent used in patients who required endoscopy for suspected acute GIB (Table 2). Smoking was more prevalent among patients with suspected acute GIB (9.1%) but was not statistically significant (P ¼ .28). Of the 12 remaining patients who required interventions, 9 (75%) underwent exploratory laparotomies in the setting of an acute abdomen. Four of the 9 (44.4%) were for obstruction, 3 (33.3%) for perforated diverticulitis, 1 (11.1%) for acute abdomen of unknown etiology, and 1 (11.1%) for the incarceration of a known hernia. Ostomy formation was required at the time of the laparotomy in 4 of these 9 patients (44.4%). Three of the 9 (33.3%) patients who underwent exploratory laparotomy (all for obstruction) died in the study period. Additionally, 2 interventions were performed for pancreatitis; one patient underwent an endoscopic retrograde cholangiopancreatography and the other patient underwent a
GI complications following TJA are uncommon but adversely affect patient outcomes. When severe, they require invasive procedures and can result in long-term patient morbidity. There are few studies that address this topic in the current literature; therefore, this study aimed to evaluate the incidence of unplanned invasive procedures for GI complications within 30 days of TJA. In our patient population, the incidence of GI complications that required invasive procedures was 0.18%. GIB was the most common complication necessitating secondary intervention in the form of endoscopy. The most common non-GIB complication requiring surgical intervention was intestinal obstruction. These cases were managed with exploratory laparotomy. The mortality rate for exploratory laparotomy in the setting of intestinal obstruction was 33.3%. GI Bleeding The reported annual incidence of acute GIB in the general population is approximately 0.03%-0.09% [27e31]. Comparatively, the incidence of GIB requiring endoscopy within 30 days of TJA was 0.12% (22/19,090 patients) in the presented patient sample. Both upper and lower GIB after TJA have been reported in the literature [32,33]. Although these events most frequently occur within the first week after surgery, studies have demonstrated that the risk remains elevated for several weeks [8,11,20]. Risk factors for postoperative GIB include pre-existing peptic ulcer disease, steroid use,
A.S. Adenikinju et al. / The Journal of Arthroplasty xxx (2019) 1e5 Table 2 Patient Demographics by Complications. Complication
Bleeding (N ¼ 22) (%)
Other (N ¼ 12) (%)
Age Gender Female Male BMI (kg/m2) ASA score 1 2 3 4 Unknown Smoking status Current smoker Former smoker Never smoker Unknown Race African American Asian Other/unknown White Procedure THA TKA Bilateral THA Bilateral TKA Thromboprophylaxis Aspirin Enoxaparin Warfarin Unknown
68.5 ± 11.0
68.9 ± 8.1
13 (59.1) 9 (40.9) 29.8 ± 6.7
7 (63.4) 5 (41.7) 31.7 ± 7
0 5 5 2 10
(22.7) (22.7) (9.1) (45.5)
0 3 3 2 4
2 7 9 4
(9.1) (31.8) (40.9) (18.2)
0 4 (33.3) 8 (66.6) 0
4 1 4 13
(18.2) (4.5) (18.2) (59.1)
2 (16.7) 0 2 (16.7) 8 (66.7)
(27.3) (27.3) (9.1) (36.4)
9 (40.9) 13 (59.1) 0 0
3 3 1 5
14 3 4 1
6 (50.0) 5 (41.7) 1 (8.3) 0
(63.6) (13.6) (18.2) (4.5)
(25.0) (25.0) (8.3) (41.7)
ASA, American Society of Anesthesiologists; BMI, body mass index; THA, total hip arthroplasty; TKA, total knee arthroplasty.
advanced age, and hypotension [11,19,22]. Smoking has also previously been identified as a risk factor [19], consistent with our finding of a higher smoking prevalence among patients who developed GIB. Non-steroidal anti-inflammatory drugs (NSAIDs) and anticoagulants are thought to play a contributing role in most cases of postoperative GIB [11,19]. Patients taking NSAIDs have been shown to have more bleeding complications after elective surgery, with higher risk associated with use of longer acting medications such as aspirin and naproxen [34]. This predisposition is important as many TJA patients are chronically managed with NSAIDs for pain control prior to surgery. Although patients are generally instructed to discontinue NSAID use the week prior to TJA, it is unclear what restorative effect this may have on their GI system prior to resuming, and likely increasing, NSAID intake in the acute postoperative period. Efforts to shift toward opioid-sparing pain protocols postoperatively may help to limit undesired narcotic sideeffects such as drowsiness, fatigue, hypotension, nausea, vomiting, and constipation [35]; however, resulting increased NSAID requirements inevitably increases the risk of other related complications, such as GIB. Aspirin was the most common venous thromboembolism (VTE) prophylaxis utilized in our patient series overall; however, aspirin use was slightly higher in the group of patients who developed GIB (63.6%) compared to other GI complications (50%). Current VTE prophylaxis protocol at our institution includes aspirin 81 mg bidaily along with the use of sequential compression devices for all patients with BMI <40 kg/m2, unless otherwise contraindicated or in the setting of other medical diagnoses requiring anticoagulation (ie, atrial fibrillation). Multiple studies have examined various anticoagulants to determine the safest and most efficacious pharmacologic agent for VTE prophylaxis after TJA [17,18,21,36]. Aspirin
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has been found to have lower risks of GIB than low molecular weight heparin and the newer oral anticoagulants, such as direct thrombin and factor Xa inhibitors [36]. Additionally, studies have shown that both aspirin 81 mg and 325 mg have equivalent efficacy of thromboprophylaxis without a difference in the incidence of GIB [17,18,21]. Dual NSAID therapy for opioid-sparing pain protocols and VTE prophylaxis continues to gain popularity in place of more aggressive anticoagulation and narcotic analgesia. Coadministration of antacid medications may be helpful in mitigating the side-effect profile of increased NSAID use in the perioperative period. Both proton pump inhibitors and H2-blockers have been shown to reduce the risk of GIB in TJA patients [19,20]. Madhusudhan et al [19] reported a lower incidence of GIB among TJA patients who received a short course of an H2-blocker from the day before surgery until postoperative day (POD) 3 compared to patients who did not (0.11% vs 0.94%, P < .05). However, while protective against bleeding complications, GI acid suppression is not without its own risks. Studies have demonstrated an increased incidence of Clostridium difficile colitis in patients taking proton pump inhibitors or H2-blockers in the general population [37e41]. Reports suggest that the risk of developing Clostridium difficile colitis is duration-dependent [37,40] and higher in patients that use proton pump inhibitors compared to H2-blockers [39,42]. Brief perioperative use of an H2-blocker may therefore be the best option to protect against GIB without introducing the risk of additional complications.
Intestinal Obstruction Most reported cases of bowel obstruction after TJA are attributed to postoperative ileus or ACPO [4,7,9,13e16], both of which typically manifest 2-4 days after surgery [10,14,15]. Although the etiology is unknown, it is theorized that increased sympathetic stimulation and impaired parasympathetic function during the postoperative period cause a decrease in peristalsis and GI motility [15,43]. Prolonged immobilization has also been described as a possible factor in the pathogenesis of postoperative bowel obstruction. The air fluid lock theory dictates that when a patient is recumbent for a prolonged period of time the dependent bowel loops collect air and fluid which, in the setting of an incompetent ileocecal valve, results in the dilation of the cecum that is characteristic of ACPO and subsequently increases the risk of perforation and ischemic necrosis [12,13,15]. Higher rates of postoperative ileus and ACPO have been reported following bilateral TKA and arthroplasty performed in the setting of trauma [10,15,16]. One study reported a greater incidence of postoperative ileus after THA compared to TKA [10], which may be partially attributed to the number of THAs performed primarily for femoral neck fractures. Additionally, a 1978 case report suggested that the use of acetabular cement may be an associated factor in the development of bowel obstruction [44]. It is hypothesized that the exothermic polymerization of cement conducts heat to the pelvis, causing an autonomic imbalance in the colon and surrounding peritonitis, which may later result in local adhesions. Though no longer the preferred method of acetabular component fixation, the pathogenesis described above may contribute to an increased risk of bowel obstruction in both the short (autonomic dysfunction) and long-term (adhesions) [44]. Other risk factors of GI obstruction include prior history of abdominal surgery, increased age, and narcotic pain medicationsdespecially patient-controlled analgesia [10,13e16,45]. Although not noted in our study, male gender has also been described as a risk factor for obstruction [10,15,16].
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Secondary Procedures for GI Complications and Patient Outcomes
Conclusion
Postoperative GIB often warrants an endoscopic procedure to identify and/or treat the source, although gastric or intestinal resection may be required in severe cases [4,11]. There have been case reports of both fatal and near fatal GIB following TJA [32,33], with mortality rates of up to 14% reported in the literature [11]. Although postoperative ileus and intestinal obstruction are initially managed conservatively, operative management of severe cases generally results in significant patient morbidity (eg, ostomy), prolonged hospitalization, and adverse functional outcomes. Thirty-day mortality rate of up to 20% following emergent laparotomy has been reported [23], consistent with the numbers seen in our study. Three patient deaths occurred following exploratory laparotomy for bowel obstruction in the presented series. One patient was readmitted on POD 7 after right THA with abdominal distension and concern for ACPO. Colonoscopy was performed initially and complicated by colonic perforation, which required exploratory laparotomy with end ileostomy. Closure of ileostomy 5 weeks later resulted in multiple complications, including ongoing ACPO and hematemesis that led to another exploratory laparotomy with bowel resection in the following weeks. One day after the second exploratory laparotomy, the patient experienced cardiopulmonary arrest and subsequently died. The second patient was readmitted 3 weeks after right THA for high grade small bowel obstruction and underwent small bowel resection with primary anastomosis the day after readmission. The postoperative course was complicated by continued ileus and sepsis, and the patient ultimately expired due to cardiopulmonary arrest 2 weeks later. The third patient was readmitted on POD 5 after bilateral TKA for partial bowel obstruction with rapid clinical deterioration. Exploratory laparotomy was performed on the day of readmission, and again along with a bowel resection the next day due to continued decompensation. The patient expired the following day (POD 7 from bilateral TKA) due to cardiomyopathy likely secondary to septic shock. Although no studies specifically evaluate the incidence or affected outcomes of secondary procedures for GI complications following TJA, there are some related reports in the cardiac surgery literature. Although one study cited a <1% incidence of GI complications following cardiac surgery, 20% of those patients required surgical intervention with an 85% postoperative mortality rate [22]. Our findings are consistent with published series; although postoperative GI complications have a low incidence, they may causeddetrimental outcomesdincluding prolonged hospital stay, increased risk of further complications, patient morbidity, and death [11,32,33,46,47].
GI complications requiring surgical intervention after TJA are rare. Suspected GIB is the most common indication for secondary intervention and is typically managed with endoscopy. Nonbleeding GI complications require more invasive interventions and have higher morbidity. As seen in our study, the risk of GI obstruction continues past the initial perioperative period, for several weeks following TJA. Given the high incidence and growing demand for TJA, future research should focus on early risk identification, prevention, and management of postoperative GI complications in this patient population.
Limitations/Future Directions This study is not without limitations. First, there are inherent limitations due to the retrospective study design. Additionally, it is possible that secondary procedures or GI complications may have been missed in our data review. Finally, the low incidence of GI complications warranting secondary procedures in our series limited our ability to identify statistically significant risk factors for GI complications and secondary procedures following TJA. A future multicenter study and/or a meta-analysis of the literature is warranted to further assess the population at risk. Given that GIB seems to be the most common postoperative GI complication affecting TJA patients, further research should investigate the efficacy of pharmacologic agents in minimizing postoperative GIB. Such efforts may prove beneficial in the standardization of postoperative care as well as the reduction associated healthcare costs.
References [1] Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States. J Bone Joint Surg Am 2014;96: 624e30. https://doi.org/10.2106/JBJS.M.00285. [2] Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780. https://doi.org/10.2106/JBJS.F.00222. [3] Parvizi J, Mui A, Purtill JJ, Sharkey PF, Hozack WJ, Rothman RH. Total joint arthroplasty. J Bone Joint Surg Am 2007;89:27e32. https://doi.org/10.2106/ JBJS.E.01443. [4] Eftekhar NS, Kiernan HA, Stinchfield FE. Systemic and local complications following low-friction arthroplasty of the hip joint. Arch Surg 1976;111:150. https://doi.org/10.1001/archsurg.1976.01360200056010. [5] Kapadia BH, Issa K, Nagrare N, Pivec R, Banerjee S, Mont MA. Higher revision and complication rates following total hip arthroplasty in patients with inflammatory bowel disease. J Arthroplasty 2014;29:596e600. https://doi.org/ 10.1016/j.arth.2013.07.011. [6] Duchman KR, Pugely AJ, Martin CT, Gao Y, Bedard NA, Callaghan JJ. Operative time affects short-term complications in total joint arthroplasty. J Arthroplasty 2017;32:1285e91. https://doi.org/10.1016/j.arth.2016.12.003. [7] Star MJ, Colwell CW, Johnson AC. Acute pseudo-obstruction of the colon following total hip arthroplasty. Orthopedics 1995;18:63e5. [8] Ficheur G, Caron A, Beuscart J-B, Ferret L, Putman S, Beuscart R, et al. The risks of pulmonary embolism and upper gastrointestinal bleeding beyond 35 days after total hip replacement for coxarthrosis among middle-aged patients: a cross-over cohort. Prev Med (Baltim) 2016;93:121e7. https://doi.org/10.1016/ j.ypmed.2016.09.010. [9] Iorio R, Healy WL, Appleby D. The association of excessive warfarin anticoagulation and postoperative ileus after total joint replacement surgery. J Arthroplasty 2000;15:220e3. [10] Parvizi J, Han S-B, Tarity TD, Pulido L, Weinstein M, Rothman RH. Postoperative ileus after total joint arthroplasty. J Arthroplasty 2008;23:360e5. https://doi.org/10.1016/j.arth.2007.12.019. [11] Sharma S. Upper gastrointestinal bleeding after hip and knee arthroplasty. Orthopedics 2006;29:255e7. [12] Nelson JD. Acute colonic pseudo-obstruction (Ogilvie syndrome) after arthroplasty in the lower extremity. J Bone Joint Surg Am 2006;88:604. https://doi.org/10.2106/JBJS.D.02864. [13] elMaraghy AW, Schemitsch EH, Burnstein MJ, Waddell JP. Ogilvie’s syndrome after lower extremity arthroplasty. Can J Surg 1999;42:133e7. [14] Clarke HD, Berry DJ, Larson DR. Acute pseudo-obstruction of the colon as a postoperative complication of hip arthroplasty. J Bone Joint Surg Am 1997;79: 1642e7. [15] Petrisor BA, Petruccelli DT, Winemaker MJ, de Beer JV. Acute colonic pseudoobstruction after elective total joint arthroplasty. J Arthroplasty 2001;16: 1043e7. [16] Yilmazlar A, Is¸çimen R, Bilgen OF, Ozgüç H. Ogilvie’s syndrome following bilateral knee arthroplasty: a case report. Acta Orthop Traumatol Turcica 2012;46:220e2. [17] Feldstein MJ, Low SL, Chen AF, Woodward LA, Hozack WJ. A comparison of two dosing regimens of ASA following total hip and knee arthroplasties. J Arthroplasty 2017;32:S157e61. https://doi.org/10.1016/J.ARTH.2017.01.009. [18] Faour M, Piuzzi NS, Brigati DP, Klika AK, Mont MA, Barsoum WK, et al. Lowdose aspirin is safe and effective for venous thromboembolism prophylaxis following total knee arthroplasty. J Arthroplasty 2018;33:S131e5. https:// doi.org/10.1016/j.arth.2018.03.001. [19] Madhusudhan TR, Rangan A, Gregg PJ. Gastric protection and gastrointestinal bleeding with aspirin thromboprophylaxis in hip and knee joint replacements. Ann R Coll Surg Engl 2008;90:332e5. https://doi.org/10.1308/ 003588408X285946. [20] Lalmohamed A, Vestergaard P, Kassim Javaid M, de Boer A, Leufkens HG M, van Staa TP, et al. Risk of gastrointestinal bleeding in patients undergoing total hip or knee replacement compared with matched controls: a nationwide cohort study. Am J Gastroenterol 2013;108:1277e85. https://doi.org/10.1038/ ajg.2013.108.
A.S. Adenikinju et al. / The Journal of Arthroplasty xxx (2019) 1e5 [21] Parvizi J, Huang R, Restrepo C, Chen AF, Austin MS, Hozack WJ, et al. Low-dose aspirin is effective chemoprophylaxis against clinically important venous thromboembolism following total joint arthroplasty. J Bone Joint Surg Am 2017;99:91e8. https://doi.org/10.2106/JBJS.16.00147. [22] Hashemzadeh K, Hashemzadeh S. Predictors and outcome of gastrointestinal complications after cardiac surgery. Minerva Chir 2012;67:327e35. € genur I, Henriksen R, et al. [23] Tengberg LT, Cihoric M, Foss NB, Bay-Nielsen M, Go Complications after emergency laparotomy beyond the immediate postoperative periodda retrospective, observational cohort study of 1139 patients. Anaesthesia 2017;72:309e16. https://doi.org/10.1111/anae.13721. [24] Sahota S, Lovecchio F, Harold RE, Beal MD, Manning DW. The effect of smoking on thirty-day postoperative complications after total joint arthroplasty: a propensity score-matched analysis. J Arthroplasty 2018;33:30e5. https://doi.org/10.1016/j.arth.2017.07.037. [25] Bozic KJ, Ward L, Vail TP, Maze M. Bundled payments in total joint arthroplasty: targeting opportunities for quality improvement and cost reduction. Clin Orthop Relat Res 2014;472:188e93. https://doi.org/10.1007/s11999-0133034-3. [26] Gray F, Prieto HA, Duncan AT, Parvataneni HK. Arthroplasty care redesign related to the Comprehensive Care for Joint Replacement model: results at a tertiary academic medical center. Arthroplast Today 2018;4:221e6. https:// doi.org/10.1016/j.artd.2018.02.002. [27] Lanas A, García-Rodríguez LA, Polo-Tom as M, Ponce M, Alonso-Abreu I, PerezAisa MA, et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol 2009;104: 1633e41. https://doi.org/10.1038/ajg.2009.164. ndez-Díaz S, Rodríguez LAG. Incidence of serious upper gastrointestinal [28] Herna bleeding/perforation in the general population: review of epidemiologic studies. J Clin Epidemiol 2002;55:157e63. [29] Laine L, Yang H, Chang S-C, Datto C. Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009. Am J Gastroenterol 2012;107:1190e5. https://doi.org/10.1038/ajg.2012.168. quiz 1196. € rnsson ES. Upper gastroin[30] Hreinsson JP, Kalaitzakis E, Gudmundsson S, Bjo testinal bleeding: incidence, etiology and outcomes in a population-based setting. Scand J Gastroenterol 2013;48:439e47. https://doi.org/10.3109/ 00365521.2012.763174. € rnsson ES. Lower gastrointes[31] Hreinsson JP, Gumundsson S, Kalaitzakis E, Bjo tinal bleeding: incidence, etiology, and outcomes in a population-based setting. Eur J Gastroenterol Hepatol 2013;25:37e43. https://doi.org/10.1097/ MEG.0b013e32835948e3. [32] Carter A, Sarda P, George M, Corbett S. Hip arthroplasty fatality related to dabigatran induced gastrointestinal haemorrhage. Ann R Coll Surg Engl 2014;96:115Ee7E. https://doi.org/10.1308/003588414X13824511649779. [33] Boland M, Murphy M, Murphy M, McDermott E. Acute-onset severe gastrointestinal tract hemorrhage in a postoperative patient taking rivaroxaban after total hip arthroplasty: a case report. J Med Case Rep 2012;6:129. https:// doi.org/10.1186/1752-1947-6-129.
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[34] Connelly CS, Panush RS. Should nonsteroidal anti-inflammatory drugs be stopped before elective surgery? Arch Intern Med 1991;151:1963. https:// doi.org/10.1001/archinte.1991.00400100049008. [35] Soffin EM, Wu CL. Regional and multimodal analgesia to reduce opioid use after total joint arthroplasty: a narrative review. HSS J 2019;15:57e65. https://doi.org/10.1007/s11420-018-9652-2. [36] Nielen JTH, Dagnelie PC, Emans PJ, Veldhorst-Janssen N, Lalmohamed A, van Staa T-P, et al. Safety and efficacy of new oral anticoagulants and lowmolecular-weight heparins compared with aspirin in patients undergoing total knee and hip replacements. Pharmacoepidemiol Drug Saf 2016;25: 1245e52. https://doi.org/10.1002/pds.4089. [37] Dial S, Alrasadi K, Manoukian C, Huang A, Menzies D. Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case-control studies. CMAJ 2004;171:33e8. https:// doi.org/10.1503/CMAJ.1040876. [38] Trifan A, Stanciu C, Girleanu I, Stoica OC, Singeap AM, Maxim R, et al. Proton pump inhibitors therapy and risk of Clostridium difficile infection: systematic review and meta-analysis. World J Gastroenterol 2017;23:6500e15. https:// doi.org/10.3748/wjg.v23.i35.6500. [39] Howell MD, Novack V, Grgurich P, Soulliard D, Novack L, Pencina M, et al. Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Arch Intern Med 2010;170:784e90. https://doi.org/10.1001/ archinternmed.2010.89. [40] Barletta JF, El-Ibiary SY, Davis LE, Nguyen B, Raney CR. Proton pump inhibitors and the risk for hospital-acquired Clostridium difficile infection. Mayo Clin Proc 2013;88:1085e90. https://doi.org/10.1016/j.mayocp.2013.07.004. [41] Jaynes M, Kumar AB. The risks of long-term use of proton pump inhibitors: a critical review. Ther Adv Drug Saf 2019;10. https://doi.org/10.1177/ 2042098618809927. 204209861880992. [42] MacLaren R, Reynolds PM, Allen RR. Histamine-2 receptor antagonists vs proton pump inhibitors on gastrointestinal tract hemorrhage and infectious complications in the intensive care unit. JAMA Intern Med 2014;174:564. https://doi.org/10.1001/jamainternmed.2013.14673. [43] Dorudi S, Berry AR, Kettlewell MGW. Acute colonic pseudo-obstruction. Br J Surg 1992;79:99e103. https://doi.org/10.1002/bjs.1800790203. [44] Foster GE, Bourke JB. Acetabular cement causing intestinal obstruction. Lancet 1978;2:267. [45] Chambers HG, Silver SM, Bucknell AL. Colonic pseudoobstruction associated with patient-controlled analgesia after total joint arthroplasty. Clin Orthop Relat Res 1990:255e60. [46] Chaudhry R, Zaki J, Wegner R, Pednekar G, Tse A, Sheinbaum R, et al. Gastrointestinal complications after cardiac surgery: a nationwide population-based analysis of morbidity and mortality predictors. J Cardiothorac Vasc Anesth 2017;31:1268e74. https://doi.org/10.1053/j.jvca.2017.04.013. [47] Mangi AA, Christison-Lagay ER, Torchiana DF, Warshaw AL, Berger DL. Gastrointestinal complications in patients undergoing heart operation: an analysis of 8709 consecutive cardiac surgical patients. Ann Surg 2005;241:895e901. https://doi.org/10.1097/01.SLA.0000164173.05762.32. discussion 901-904.
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Gastrointestinal Complications Warranting Invasive Interventions Following Total Joint Arthroplasty Abidemi S. Adenikinju, MD *, James E. Feng, MD, Clementine A. Namba, MHS, Tyler A. Luthringer, MD, Claudette M. Lajam, MD Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 March 2019 Received in revised form 24 May 2019 Accepted 8 June 2019 Available online xxx
Background: Gastrointestinal (GI) complications following total joint arthroplasty (TJA) are uncommon but can be associated with substantial morbidity and mortality. The current literature on GI complications that warrant invasive procedures after TJA is lacking. This study reviews the incidence and outcomes of GI complications after TJA that went on to require invasive procedures. Methods: All TJA patients at our institution between January 2012 and May 2018 who had GI complications requiring an invasive procedure within 30 days of TJA were identified and retrospectively chart reviewed. Descriptive statistics were used to evaluate these patients. Results: Of 19,090 TJAs in a 6-year period, 34 patients (0.18%) required invasive procedures for GI complications within 30 days of the index surgery. Twenty-two (64%) of the required procedures were endoscopy for suspected GI bleeding. Within this cohort, aspirin was the most common thromboprophylaxis used (63.6% of patients) and smoking was more prevalent (9.1% current smokers) (P ¼ .28). Of the remaining 12 GI procedures required, 75% were exploratory laparotomies, 44.4% of which were performed for obstruction. Three (33.3%) of the exploratory laparotomy patients died during the study period. Conclusion: GI complications necessitating surgical intervention after TJA are rare. Suspected GI bleeding is the most common indication for intervention and is typically managed endoscopically. Other complications, such as GI obstruction, often require more extensive intervention and open procedures. Though rare, GI complications following TJA can lead to detrimental outcomes, significant patient morbidity, and occasionally mortality; therefore, a heightened awareness of these complications is warranted. © 2019 Elsevier Inc. All rights reserved.
Keywords: total joint arthroplasty complications total hip arthroplasty complications total knee arthroplasty complications gastrointestinal complications
Over the last century, total hip (THA) and total knee arthroplasties (TKA) have evolved into immensely successful procedures for relieving pain and restoring function in patients suffering from joint pathology. Over 1,000,000 hip and knee total joint arthroplasties (TJAs) are performed annually in the United States alone, and this number is expected to reach 4,000,000 by 2030 [1,2].
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 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 https://doi.org/10.1016/j.arth.2019.06.026. * Reprint requests: Abidemi S. Adenikinju, MD, NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003. https://doi.org/10.1016/j.arth.2019.06.026 0883-5403/© 2019 Elsevier Inc. All rights reserved.
Although TJA is generally safe, systemic complications secondary to the insult of surgery (unrelated to the prostheses) can and do occur [3,4]. A few risk factors for such complications include older age, higher body mass index (BMI), pre-existing medical comorbidities, and longer operative time [3,5,6]. Gastrointestinal (GI) complications following TJA are uncommon but can be associated with substantial morbidity and mortality. Reported complications include acute colonic pseudoobstruction (ACPO), GI bleeding (GIB), pancreatitis, diverticulitis, and intestinal ischemia [4,7e20]. The incidence of each complication varies by series, with ACPO and GIB occurring in up to 4% [4,9,14e16] and 4.5% [4,11,14,21] of TJA patients, respectively. These complications typically occur in the acute postoperative period, within 1 to 2 weeks after surgery [8,11,14,15,20]. Although managed conservatively when possible, severe cases may warrant surgical intervention, including endoscopy, laparoscopy, and laparotomy
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with possible gastric or bowel resection [4,10,11,15,22]. These secondary invasive procedures increase patient length of stay, risk of further complications, overall patient morbidity and mortality, as well as healthcare costs [23]. GI complications requiring secondary procedures after TJA are rarely addressed in the current literature. Given that TJA complications and patient outcomes are used to assess hospital performance and affect new payment models, a greater understanding of the incidence, risk factors, and possible prevention of these complications is necessary [24e26]. This study evaluates the incidence and outcomes of GI complications requiring invasive procedures within 30 days of THA and TKA. Materials and Methods This study is a retrospective observational quality study conducted at a single tertiary academic care center with a dedicated, high-volume orthopedic hospital. All patients who underwent unilateral or bilateral primary THA or TKA and had a second procedure within 30 days of the index TJA between January 2012 and May 2018 were included. Subjects were identified by our electronic medical record database. Patients with secondary surgical procedures other than colonoscopy, sigmoidoscopy, laparotomy, laparoscopy, or esophagogastroduodenoscopy were excluded. Patients who had more than one of the same GI procedure for the same complication were only included once. Demographics including patient age, gender, BMI, procedure type, race, smoking status, insurance type, comorbidities, and American Society of Anesthesiologists score were collected for all subjects. Perioperative variables from the index TJA were also collected, including thromboprophylaxis, surgical time, and discharge disposition. All queried data were retrieved using Microsoft SQL Server Management Studio 2017 (Richmond, WA). Statistical analysis was performed using MATLAB 2018a (MathWorks, Natick, MA). Demographics and surgical variables were summarized by standard descriptive summaries (eg, means and standard deviations for continuous variables).
Table 1 Patient Demographics. Characteristics
N ¼ 34 (%)
Age Gender Female Male BMI (kg/m2) ASA score 1 2 3 4 Unknown Smoking status Current smoker Former smoker Never smoker Unknown Race African American Asian Other/unknown White Procedure THA TKA Bilateral THA Bilateral TKA Thromboprophylaxis Aspirin Enoxaparin Warfarin Unknown
69 ± 10.2 18 (53.9) 16 (47.1) 30.5 ± 6.9 0 8 9 3 14
(23.5) (26.5) (23.5) (41.2)
2 11 17 4
(5.9) (28.9) (50) (11.8)
6 1 6 21
(17.6) (3) (17.6) (61)
14 16 1 3
(41.2) (47.1) (3) (8.8)
21 6 6 1
(64.7) (14.7) (17.6) (3)
ASA, American Society of Anesthesiologists; BMI, body mass index; THA, total hip arthroplasty; TKA, total knee arthroplasty.
cholecystectomy. Finally, one esophagogastroduodenoscopy was performed for variceal screening prior to transesophageal echocardiogram that was needed to evaluate for endocarditis. Discussion
Results In total, 19,090 TJAs in a 6-year period were examined. Thirtyfour patients (0.18%) required secondary invasive procedures for GI complications within 30 days of their index TJA. The mean age of patients requiring secondary procedures was 69 ± 10.2 years, with an average BMI of 30.5 ± 6.9 (Table 1). There was no gender predilection among those requiring secondary GI procedures (Table 1). Of the 34 patients who required GI intervention, 22 (64.7%) underwent low-risk GI procedures (endoscopy) for suspected acute GIB. Aspirin (63.6%) was the most common thromboprophylaxis agent used in patients who required endoscopy for suspected acute GIB (Table 2). Smoking was more prevalent among patients with suspected acute GIB (9.1%) but was not statistically significant (P ¼ .28). Of the 12 remaining patients who required interventions, 9 (75%) underwent exploratory laparotomies in the setting of an acute abdomen. Four of the 9 (44.4%) were for obstruction, 3 (33.3%) for perforated diverticulitis, 1 (11.1%) for acute abdomen of unknown etiology, and 1 (11.1%) for the incarceration of a known hernia. Ostomy formation was required at the time of the laparotomy in 4 of these 9 patients (44.4%). Three of the 9 (33.3%) patients who underwent exploratory laparotomy (all for obstruction) died in the study period. Additionally, 2 interventions were performed for pancreatitis; one patient underwent an endoscopic retrograde cholangiopancreatography and the other patient underwent a
GI complications following TJA are uncommon but adversely affect patient outcomes. When severe, they require invasive procedures and can result in long-term patient morbidity. There are few studies that address this topic in the current literature; therefore, this study aimed to evaluate the incidence of unplanned invasive procedures for GI complications within 30 days of TJA. In our patient population, the incidence of GI complications that required invasive procedures was 0.18%. GIB was the most common complication necessitating secondary intervention in the form of endoscopy. The most common non-GIB complication requiring surgical intervention was intestinal obstruction. These cases were managed with exploratory laparotomy. The mortality rate for exploratory laparotomy in the setting of intestinal obstruction was 33.3%. GI Bleeding The reported annual incidence of acute GIB in the general population is approximately 0.03%-0.09% [27e31]. Comparatively, the incidence of GIB requiring endoscopy within 30 days of TJA was 0.12% (22/19,090 patients) in the presented patient sample. Both upper and lower GIB after TJA have been reported in the literature [32,33]. Although these events most frequently occur within the first week after surgery, studies have demonstrated that the risk remains elevated for several weeks [8,11,20]. Risk factors for postoperative GIB include pre-existing peptic ulcer disease, steroid use,
A.S. Adenikinju et al. / The Journal of Arthroplasty xxx (2019) 1e5 Table 2 Patient Demographics by Complications. Complication
Bleeding (N ¼ 22) (%)
Other (N ¼ 12) (%)
Age Gender Female Male BMI (kg/m2) ASA score 1 2 3 4 Unknown Smoking status Current smoker Former smoker Never smoker Unknown Race African American Asian Other/unknown White Procedure THA TKA Bilateral THA Bilateral TKA Thromboprophylaxis Aspirin Enoxaparin Warfarin Unknown
68.5 ± 11.0
68.9 ± 8.1
13 (59.1) 9 (40.9) 29.8 ± 6.7
7 (63.4) 5 (41.7) 31.7 ± 7
0 5 5 2 10
(22.7) (22.7) (9.1) (45.5)
0 3 3 2 4
2 7 9 4
(9.1) (31.8) (40.9) (18.2)
0 4 (33.3) 8 (66.6) 0
4 1 4 13
(18.2) (4.5) (18.2) (59.1)
2 (16.7) 0 2 (16.7) 8 (66.7)
(27.3) (27.3) (9.1) (36.4)
9 (40.9) 13 (59.1) 0 0
3 3 1 5
14 3 4 1
6 (50.0) 5 (41.7) 1 (8.3) 0
(63.6) (13.6) (18.2) (4.5)
(25.0) (25.0) (8.3) (41.7)
ASA, American Society of Anesthesiologists; BMI, body mass index; THA, total hip arthroplasty; TKA, total knee arthroplasty.
advanced age, and hypotension [11,19,22]. Smoking has also previously been identified as a risk factor [19], consistent with our finding of a higher smoking prevalence among patients who developed GIB. Non-steroidal anti-inflammatory drugs (NSAIDs) and anticoagulants are thought to play a contributing role in most cases of postoperative GIB [11,19]. Patients taking NSAIDs have been shown to have more bleeding complications after elective surgery, with higher risk associated with use of longer acting medications such as aspirin and naproxen [34]. This predisposition is important as many TJA patients are chronically managed with NSAIDs for pain control prior to surgery. Although patients are generally instructed to discontinue NSAID use the week prior to TJA, it is unclear what restorative effect this may have on their GI system prior to resuming, and likely increasing, NSAID intake in the acute postoperative period. Efforts to shift toward opioid-sparing pain protocols postoperatively may help to limit undesired narcotic sideeffects such as drowsiness, fatigue, hypotension, nausea, vomiting, and constipation [35]; however, resulting increased NSAID requirements inevitably increases the risk of other related complications, such as GIB. Aspirin was the most common venous thromboembolism (VTE) prophylaxis utilized in our patient series overall; however, aspirin use was slightly higher in the group of patients who developed GIB (63.6%) compared to other GI complications (50%). Current VTE prophylaxis protocol at our institution includes aspirin 81 mg bidaily along with the use of sequential compression devices for all patients with BMI <40 kg/m2, unless otherwise contraindicated or in the setting of other medical diagnoses requiring anticoagulation (ie, atrial fibrillation). Multiple studies have examined various anticoagulants to determine the safest and most efficacious pharmacologic agent for VTE prophylaxis after TJA [17,18,21,36]. Aspirin
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has been found to have lower risks of GIB than low molecular weight heparin and the newer oral anticoagulants, such as direct thrombin and factor Xa inhibitors [36]. Additionally, studies have shown that both aspirin 81 mg and 325 mg have equivalent efficacy of thromboprophylaxis without a difference in the incidence of GIB [17,18,21]. Dual NSAID therapy for opioid-sparing pain protocols and VTE prophylaxis continues to gain popularity in place of more aggressive anticoagulation and narcotic analgesia. Coadministration of antacid medications may be helpful in mitigating the side-effect profile of increased NSAID use in the perioperative period. Both proton pump inhibitors and H2-blockers have been shown to reduce the risk of GIB in TJA patients [19,20]. Madhusudhan et al [19] reported a lower incidence of GIB among TJA patients who received a short course of an H2-blocker from the day before surgery until postoperative day (POD) 3 compared to patients who did not (0.11% vs 0.94%, P < .05). However, while protective against bleeding complications, GI acid suppression is not without its own risks. Studies have demonstrated an increased incidence of Clostridium difficile colitis in patients taking proton pump inhibitors or H2-blockers in the general population [37e41]. Reports suggest that the risk of developing Clostridium difficile colitis is duration-dependent [37,40] and higher in patients that use proton pump inhibitors compared to H2-blockers [39,42]. Brief perioperative use of an H2-blocker may therefore be the best option to protect against GIB without introducing the risk of additional complications.
Intestinal Obstruction Most reported cases of bowel obstruction after TJA are attributed to postoperative ileus or ACPO [4,7,9,13e16], both of which typically manifest 2-4 days after surgery [10,14,15]. Although the etiology is unknown, it is theorized that increased sympathetic stimulation and impaired parasympathetic function during the postoperative period cause a decrease in peristalsis and GI motility [15,43]. Prolonged immobilization has also been described as a possible factor in the pathogenesis of postoperative bowel obstruction. The air fluid lock theory dictates that when a patient is recumbent for a prolonged period of time the dependent bowel loops collect air and fluid which, in the setting of an incompetent ileocecal valve, results in the dilation of the cecum that is characteristic of ACPO and subsequently increases the risk of perforation and ischemic necrosis [12,13,15]. Higher rates of postoperative ileus and ACPO have been reported following bilateral TKA and arthroplasty performed in the setting of trauma [10,15,16]. One study reported a greater incidence of postoperative ileus after THA compared to TKA [10], which may be partially attributed to the number of THAs performed primarily for femoral neck fractures. Additionally, a 1978 case report suggested that the use of acetabular cement may be an associated factor in the development of bowel obstruction [44]. It is hypothesized that the exothermic polymerization of cement conducts heat to the pelvis, causing an autonomic imbalance in the colon and surrounding peritonitis, which may later result in local adhesions. Though no longer the preferred method of acetabular component fixation, the pathogenesis described above may contribute to an increased risk of bowel obstruction in both the short (autonomic dysfunction) and long-term (adhesions) [44]. Other risk factors of GI obstruction include prior history of abdominal surgery, increased age, and narcotic pain medicationsdespecially patient-controlled analgesia [10,13e16,45]. Although not noted in our study, male gender has also been described as a risk factor for obstruction [10,15,16].
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Secondary Procedures for GI Complications and Patient Outcomes
Conclusion
Postoperative GIB often warrants an endoscopic procedure to identify and/or treat the source, although gastric or intestinal resection may be required in severe cases [4,11]. There have been case reports of both fatal and near fatal GIB following TJA [32,33], with mortality rates of up to 14% reported in the literature [11]. Although postoperative ileus and intestinal obstruction are initially managed conservatively, operative management of severe cases generally results in significant patient morbidity (eg, ostomy), prolonged hospitalization, and adverse functional outcomes. Thirty-day mortality rate of up to 20% following emergent laparotomy has been reported [23], consistent with the numbers seen in our study. Three patient deaths occurred following exploratory laparotomy for bowel obstruction in the presented series. One patient was readmitted on POD 7 after right THA with abdominal distension and concern for ACPO. Colonoscopy was performed initially and complicated by colonic perforation, which required exploratory laparotomy with end ileostomy. Closure of ileostomy 5 weeks later resulted in multiple complications, including ongoing ACPO and hematemesis that led to another exploratory laparotomy with bowel resection in the following weeks. One day after the second exploratory laparotomy, the patient experienced cardiopulmonary arrest and subsequently died. The second patient was readmitted 3 weeks after right THA for high grade small bowel obstruction and underwent small bowel resection with primary anastomosis the day after readmission. The postoperative course was complicated by continued ileus and sepsis, and the patient ultimately expired due to cardiopulmonary arrest 2 weeks later. The third patient was readmitted on POD 5 after bilateral TKA for partial bowel obstruction with rapid clinical deterioration. Exploratory laparotomy was performed on the day of readmission, and again along with a bowel resection the next day due to continued decompensation. The patient expired the following day (POD 7 from bilateral TKA) due to cardiomyopathy likely secondary to septic shock. Although no studies specifically evaluate the incidence or affected outcomes of secondary procedures for GI complications following TJA, there are some related reports in the cardiac surgery literature. Although one study cited a <1% incidence of GI complications following cardiac surgery, 20% of those patients required surgical intervention with an 85% postoperative mortality rate [22]. Our findings are consistent with published series; although postoperative GI complications have a low incidence, they may causeddetrimental outcomesdincluding prolonged hospital stay, increased risk of further complications, patient morbidity, and death [11,32,33,46,47].
GI complications requiring surgical intervention after TJA are rare. Suspected GIB is the most common indication for secondary intervention and is typically managed with endoscopy. Nonbleeding GI complications require more invasive interventions and have higher morbidity. As seen in our study, the risk of GI obstruction continues past the initial perioperative period, for several weeks following TJA. Given the high incidence and growing demand for TJA, future research should focus on early risk identification, prevention, and management of postoperative GI complications in this patient population.
Limitations/Future Directions This study is not without limitations. First, there are inherent limitations due to the retrospective study design. Additionally, it is possible that secondary procedures or GI complications may have been missed in our data review. Finally, the low incidence of GI complications warranting secondary procedures in our series limited our ability to identify statistically significant risk factors for GI complications and secondary procedures following TJA. A future multicenter study and/or a meta-analysis of the literature is warranted to further assess the population at risk. Given that GIB seems to be the most common postoperative GI complication affecting TJA patients, further research should investigate the efficacy of pharmacologic agents in minimizing postoperative GIB. Such efforts may prove beneficial in the standardization of postoperative care as well as the reduction associated healthcare costs.
References [1] Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States. J Bone Joint Surg Am 2014;96: 624e30. https://doi.org/10.2106/JBJS.M.00285. [2] Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780. https://doi.org/10.2106/JBJS.F.00222. [3] Parvizi J, Mui A, Purtill JJ, Sharkey PF, Hozack WJ, Rothman RH. Total joint arthroplasty. J Bone Joint Surg Am 2007;89:27e32. https://doi.org/10.2106/ JBJS.E.01443. [4] Eftekhar NS, Kiernan HA, Stinchfield FE. Systemic and local complications following low-friction arthroplasty of the hip joint. Arch Surg 1976;111:150. https://doi.org/10.1001/archsurg.1976.01360200056010. [5] Kapadia BH, Issa K, Nagrare N, Pivec R, Banerjee S, Mont MA. Higher revision and complication rates following total hip arthroplasty in patients with inflammatory bowel disease. J Arthroplasty 2014;29:596e600. https://doi.org/ 10.1016/j.arth.2013.07.011. [6] Duchman KR, Pugely AJ, Martin CT, Gao Y, Bedard NA, Callaghan JJ. Operative time affects short-term complications in total joint arthroplasty. J Arthroplasty 2017;32:1285e91. https://doi.org/10.1016/j.arth.2016.12.003. [7] Star MJ, Colwell CW, Johnson AC. Acute pseudo-obstruction of the colon following total hip arthroplasty. Orthopedics 1995;18:63e5. [8] Ficheur G, Caron A, Beuscart J-B, Ferret L, Putman S, Beuscart R, et al. The risks of pulmonary embolism and upper gastrointestinal bleeding beyond 35 days after total hip replacement for coxarthrosis among middle-aged patients: a cross-over cohort. Prev Med (Baltim) 2016;93:121e7. https://doi.org/10.1016/ j.ypmed.2016.09.010. [9] Iorio R, Healy WL, Appleby D. The association of excessive warfarin anticoagulation and postoperative ileus after total joint replacement surgery. J Arthroplasty 2000;15:220e3. [10] Parvizi J, Han S-B, Tarity TD, Pulido L, Weinstein M, Rothman RH. Postoperative ileus after total joint arthroplasty. J Arthroplasty 2008;23:360e5. https://doi.org/10.1016/j.arth.2007.12.019. [11] Sharma S. Upper gastrointestinal bleeding after hip and knee arthroplasty. Orthopedics 2006;29:255e7. [12] Nelson JD. Acute colonic pseudo-obstruction (Ogilvie syndrome) after arthroplasty in the lower extremity. J Bone Joint Surg Am 2006;88:604. https://doi.org/10.2106/JBJS.D.02864. [13] elMaraghy AW, Schemitsch EH, Burnstein MJ, Waddell JP. Ogilvie’s syndrome after lower extremity arthroplasty. Can J Surg 1999;42:133e7. [14] Clarke HD, Berry DJ, Larson DR. Acute pseudo-obstruction of the colon as a postoperative complication of hip arthroplasty. J Bone Joint Surg Am 1997;79: 1642e7. [15] Petrisor BA, Petruccelli DT, Winemaker MJ, de Beer JV. Acute colonic pseudoobstruction after elective total joint arthroplasty. J Arthroplasty 2001;16: 1043e7. [16] Yilmazlar A, Is¸çimen R, Bilgen OF, Ozgüç H. Ogilvie’s syndrome following bilateral knee arthroplasty: a case report. Acta Orthop Traumatol Turcica 2012;46:220e2. [17] Feldstein MJ, Low SL, Chen AF, Woodward LA, Hozack WJ. A comparison of two dosing regimens of ASA following total hip and knee arthroplasties. J Arthroplasty 2017;32:S157e61. https://doi.org/10.1016/J.ARTH.2017.01.009. [18] Faour M, Piuzzi NS, Brigati DP, Klika AK, Mont MA, Barsoum WK, et al. Lowdose aspirin is safe and effective for venous thromboembolism prophylaxis following total knee arthroplasty. J Arthroplasty 2018;33:S131e5. https:// doi.org/10.1016/j.arth.2018.03.001. [19] Madhusudhan TR, Rangan A, Gregg PJ. Gastric protection and gastrointestinal bleeding with aspirin thromboprophylaxis in hip and knee joint replacements. Ann R Coll Surg Engl 2008;90:332e5. https://doi.org/10.1308/ 003588408X285946. [20] Lalmohamed A, Vestergaard P, Kassim Javaid M, de Boer A, Leufkens HG M, van Staa TP, et al. Risk of gastrointestinal bleeding in patients undergoing total hip or knee replacement compared with matched controls: a nationwide cohort study. Am J Gastroenterol 2013;108:1277e85. https://doi.org/10.1038/ ajg.2013.108.
A.S. Adenikinju et al. / The Journal of Arthroplasty xxx (2019) 1e5 [21] Parvizi J, Huang R, Restrepo C, Chen AF, Austin MS, Hozack WJ, et al. Low-dose aspirin is effective chemoprophylaxis against clinically important venous thromboembolism following total joint arthroplasty. J Bone Joint Surg Am 2017;99:91e8. https://doi.org/10.2106/JBJS.16.00147. [22] Hashemzadeh K, Hashemzadeh S. Predictors and outcome of gastrointestinal complications after cardiac surgery. Minerva Chir 2012;67:327e35. € genur I, Henriksen R, et al. [23] Tengberg LT, Cihoric M, Foss NB, Bay-Nielsen M, Go Complications after emergency laparotomy beyond the immediate postoperative periodda retrospective, observational cohort study of 1139 patients. Anaesthesia 2017;72:309e16. https://doi.org/10.1111/anae.13721. [24] Sahota S, Lovecchio F, Harold RE, Beal MD, Manning DW. The effect of smoking on thirty-day postoperative complications after total joint arthroplasty: a propensity score-matched analysis. J Arthroplasty 2018;33:30e5. https://doi.org/10.1016/j.arth.2017.07.037. [25] Bozic KJ, Ward L, Vail TP, Maze M. Bundled payments in total joint arthroplasty: targeting opportunities for quality improvement and cost reduction. Clin Orthop Relat Res 2014;472:188e93. https://doi.org/10.1007/s11999-0133034-3. [26] Gray F, Prieto HA, Duncan AT, Parvataneni HK. Arthroplasty care redesign related to the Comprehensive Care for Joint Replacement model: results at a tertiary academic medical center. Arthroplast Today 2018;4:221e6. https:// doi.org/10.1016/j.artd.2018.02.002. [27] Lanas A, García-Rodríguez LA, Polo-Tom as M, Ponce M, Alonso-Abreu I, PerezAisa MA, et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol 2009;104: 1633e41. https://doi.org/10.1038/ajg.2009.164. ndez-Díaz S, Rodríguez LAG. Incidence of serious upper gastrointestinal [28] Herna bleeding/perforation in the general population: review of epidemiologic studies. J Clin Epidemiol 2002;55:157e63. [29] Laine L, Yang H, Chang S-C, Datto C. Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009. Am J Gastroenterol 2012;107:1190e5. https://doi.org/10.1038/ajg.2012.168. quiz 1196. € rnsson ES. Upper gastroin[30] Hreinsson JP, Kalaitzakis E, Gudmundsson S, Bjo testinal bleeding: incidence, etiology and outcomes in a population-based setting. Scand J Gastroenterol 2013;48:439e47. https://doi.org/10.3109/ 00365521.2012.763174. € rnsson ES. Lower gastrointes[31] Hreinsson JP, Gumundsson S, Kalaitzakis E, Bjo tinal bleeding: incidence, etiology, and outcomes in a population-based setting. Eur J Gastroenterol Hepatol 2013;25:37e43. https://doi.org/10.1097/ MEG.0b013e32835948e3. [32] Carter A, Sarda P, George M, Corbett S. Hip arthroplasty fatality related to dabigatran induced gastrointestinal haemorrhage. Ann R Coll Surg Engl 2014;96:115Ee7E. https://doi.org/10.1308/003588414X13824511649779. [33] Boland M, Murphy M, Murphy M, McDermott E. Acute-onset severe gastrointestinal tract hemorrhage in a postoperative patient taking rivaroxaban after total hip arthroplasty: a case report. J Med Case Rep 2012;6:129. https:// doi.org/10.1186/1752-1947-6-129.
5
[34] Connelly CS, Panush RS. Should nonsteroidal anti-inflammatory drugs be stopped before elective surgery? Arch Intern Med 1991;151:1963. https:// doi.org/10.1001/archinte.1991.00400100049008. [35] Soffin EM, Wu CL. Regional and multimodal analgesia to reduce opioid use after total joint arthroplasty: a narrative review. HSS J 2019;15:57e65. https://doi.org/10.1007/s11420-018-9652-2. [36] Nielen JTH, Dagnelie PC, Emans PJ, Veldhorst-Janssen N, Lalmohamed A, van Staa T-P, et al. Safety and efficacy of new oral anticoagulants and lowmolecular-weight heparins compared with aspirin in patients undergoing total knee and hip replacements. Pharmacoepidemiol Drug Saf 2016;25: 1245e52. https://doi.org/10.1002/pds.4089. [37] Dial S, Alrasadi K, Manoukian C, Huang A, Menzies D. Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case-control studies. CMAJ 2004;171:33e8. https:// doi.org/10.1503/CMAJ.1040876. [38] Trifan A, Stanciu C, Girleanu I, Stoica OC, Singeap AM, Maxim R, et al. Proton pump inhibitors therapy and risk of Clostridium difficile infection: systematic review and meta-analysis. World J Gastroenterol 2017;23:6500e15. https:// doi.org/10.3748/wjg.v23.i35.6500. [39] Howell MD, Novack V, Grgurich P, Soulliard D, Novack L, Pencina M, et al. Iatrogenic gastric acid suppression and the risk of nosocomial Clostridium difficile infection. Arch Intern Med 2010;170:784e90. https://doi.org/10.1001/ archinternmed.2010.89. [40] Barletta JF, El-Ibiary SY, Davis LE, Nguyen B, Raney CR. Proton pump inhibitors and the risk for hospital-acquired Clostridium difficile infection. Mayo Clin Proc 2013;88:1085e90. https://doi.org/10.1016/j.mayocp.2013.07.004. [41] Jaynes M, Kumar AB. The risks of long-term use of proton pump inhibitors: a critical review. Ther Adv Drug Saf 2019;10. https://doi.org/10.1177/ 2042098618809927. 204209861880992. [42] MacLaren R, Reynolds PM, Allen RR. Histamine-2 receptor antagonists vs proton pump inhibitors on gastrointestinal tract hemorrhage and infectious complications in the intensive care unit. JAMA Intern Med 2014;174:564. https://doi.org/10.1001/jamainternmed.2013.14673. [43] Dorudi S, Berry AR, Kettlewell MGW. Acute colonic pseudo-obstruction. Br J Surg 1992;79:99e103. https://doi.org/10.1002/bjs.1800790203. [44] Foster GE, Bourke JB. Acetabular cement causing intestinal obstruction. Lancet 1978;2:267. [45] Chambers HG, Silver SM, Bucknell AL. Colonic pseudoobstruction associated with patient-controlled analgesia after total joint arthroplasty. Clin Orthop Relat Res 1990:255e60. [46] Chaudhry R, Zaki J, Wegner R, Pednekar G, Tse A, Sheinbaum R, et al. Gastrointestinal complications after cardiac surgery: a nationwide population-based analysis of morbidity and mortality predictors. J Cardiothorac Vasc Anesth 2017;31:1268e74. https://doi.org/10.1053/j.jvca.2017.04.013. [47] Mangi AA, Christison-Lagay ER, Torchiana DF, Warshaw AL, Berger DL. Gastrointestinal complications in patients undergoing heart operation: an analysis of 8709 consecutive cardiac surgical patients. Ann Surg 2005;241:895e901. https://doi.org/10.1097/01.SLA.0000164173.05762.32. discussion 901-904.