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Total knee arthroplasty in patients with cardiomyopathy: A large matched cohort analysis
⁎Corresponding author: Hayden Flume. haydenflume@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Patients with cardiomyopathy, such as primary, infectious, inflammatory, secondary, and unspecified cardiomyopathy, may need total knee arthroplasty. This study aims to investigate the demographic and thirty-day postoperative complications of patients with cardiomyopathy who receive TKA.
The PearlDiver database was utilized to develop a retrospective cohort study. Patients of all demographics diagnosed with cardiomyopathy who underwent TKA based on the ICD-9, ICD-10, and CPT diagnosis codes were included. A collection of preoperative and postoperative variables was compared between patients with cardiomyopathy and those without cardiomyopathy following TKA. A matched and unmatched univariant analysis was conducted to compare these two populations using a 1:1 propensity match algorithm. Statistical significance was set at p < 0.05, and odds ratios with 95 % confidence intervals were reported.
In 163,625 patients with cardiomyopathy, patients were older and had a 3.076 times greater risk of congestive heart failure (p < 0.0001), 2.4537 times greater risk of acute myocardial infarction (p < 0.0001), 1.995 times greater risk of postoperative shock (p < 0.0001), 1.2483 times greater risk of deep vein thrombosis (p < 0.0001), 1.5590 times greater risk of pulmonary embolism (p < 0.0001), 1.3694 times greater risk of sepsis (p < 0.0001), 1.3572 times greater risk of acute kidney injury (p < 0.0001)., 1.2277 times greater risk of readmissions (p < 0.0001), 1.2588 times greater risk of revisions (p < 0.0001), and higher risks of local complications such as periprosthetic joint infection (p = 0.0397), periprosthetic mechanical complication (p = 0.0213), manipulation under anesthesia (p = 0.0012) and wound dehiscence (p < 0.0001).
Cardiomyopathy is associated with an increased risk of congestive heart failure, acute myocardial infarction, postoperative shock, deep vein thrombosis, pulmonary embolism, sepsis, acute kidney injury, readmissions, revisions, periprosthetic joint infection, mechanical complications, manipulation under anesthesia, and wound dehiscence. These results suggest that cardiomyopathy is a critical risk factor of adverse postoperative outcomes following TKA.
1 Introduction
Total knee arthroplasty (TKA) is one of the most performed orthopedic procedures and continues to become more prevalent.1 One study noted the rate of patients having at least one comorbidity who underwent TKA in 2005 compared to 2018 has significantly increased from 22 % to 41 %.2 With increased comorbidities, such as cardiac disease, there are increased risks for complications, including cardiac and thrombotic events.3 Cardiomyopathy is defined as a myocardial disorder that results in poor cardiac functioning due to structural or physiological abnormalities.4–8 The multitude of etiologies can be subdivided into primary, infectious, inflammatory, secondary, and unspecified cardiomyopathy.9 The most common, primary cardiomyopathies are further subdivided into dilated,10 hypertrophic,11 restrictive,12 and arrhythmogenic13 in descending order of prevalence. While it's not uncommon, the prevalence of cardiomyopathy varies depending on the etiology. Subdivisions of primary cardiomyopathies, such as hypertrophic cardiomyopathy, have a prevalence of 1:500 persons, while dilated is 1:2500 persons, and restrictive occurs only in around 2–5 % of patients.14 Secondary causes, such as alcohol-induced cardiomyopathy, constitute around 10 % of dilated cardiomyopathies.15 Additionally, myocarditis is diagnosed in 10.2–105.6 per 100,000 worldwide and manifests in around 1.8 million patients.16
Patients with cardiomyopathy alone are already at an increased risk for severe medical conditions including heart failure, arrhythmias, sudden cardiac death, edema, and stroke.17There are currently no studies comparing the rates of complications in TKA patients with some form of cardiomyopathy to patients without cardiomyopathy. With such a high case volume of TKA and the prevalence of cardiomyopathy, it's imperative to analyze the adverse effects that may arise. This study aims to examine the impact of cardiomyopathy on the demographic and immediate postoperative outcomes in patients following TKA.
2 Methods
2.1 Database description
This study utilized the Pearl Diver Patient Records Database, a large, de-identified commercial claims and Medicare database that consists of longitudinal healthcare data from broad populations of insured and uninsured patients. This database consists of demographic characteristics, hospital charges, payment sources, International Classification of Disease 9th and 10 edition diagnosis codes (ICD-9/10), Current Procedural Terminology codes (CPT), prescription records, discharge status, and comorbidities, making it a beneficial platform for retrospective cohort studies.
2.2 Data acquisition
The data was de-identified and publicly available in PearlDiver, thus exempting this study from institutional review board approval and being compliant with the Health Insurance Portability and Accountability Act (HIPAA). Patients who underwent TKA were identified using CPT procedure codes (CPT-27447), and patients with cardiomyopathy were identified with ICD-9 and ICD-10 diagnosis codes (Appendix 1). Preoperative comorbidities included diabetes, obesity, and tobacco use, and were identified using ICD-9 and 10 codes (Appendix 1). Preoperative demographic variables included sex, gender, primary payer, service location, Charlson Score, and Elixhauser Score (Tables 1 and 3). Postoperative medical and surgical outcomes after 30 days of TKA complied from PearlDiver consisted of Respiratory Failure, Urinary Tract Infection, Postoperative Shock, Postoperative Infection, Deep Vein Thrombosis, Pulmonary Embolism, Disruption of Wound, Revisions, Readmissions, Acute Kidney Injury, Acute Myocardial Infarction, Cardiac Arrest, Cardiac Arrhythmia, Congestive Heart Failure, Hematoma/Hemorrhage, Pneumonia, Sepsis, Periprosthetic Joint Infection, Periprosthetic, Dislocation, Periprosthetic Mechanical Complication, Periprosthetic Fracture, Stiffness, Manipulation Under Anesthesia (MUA), Superficial Incision Infection, Deep Incision Infection (Appendix 1). Readmissions within 90 days and Revisions within 2 years were also compiled. These variables were some of the most common complications in the PearlDiver predefined cohorts and the literature on TKA and Cardiomyopathy patients.
| Demographic | Non-Cardiomyopathy (%) n = 1,535,586 | Cardiomyopathy (%) n = 167,911 | p-value | Odds Ratio (Study Cohort/Control) | Odds Ratio 95 % Confidence Interval |
| Genders | |||||
| Male | 559624 (36.44) | 77993 (46.45) | <0.0001 | 1.51 | 1.50–1.53 |
| Female | 975959 (63.56) | 89918 (53.55) | <0.0001 | 0.66 | 0.65–0.67 |
| Age | |||||
| >20 | 373 (0.02) | 45 (0.03) | 0.5332 | – | – |
| 20–39 | 5697 (0.37) | 389 (0.23) | <0.0001 | 0.62 | 0.56–0.69 |
| 40–49 | 56272 (3.67) | 3741 (2.23) | <0.0001 | 0.60 | 0.58–0.62 |
| 50–59 | 309702 (20.17) | 24215 (14.42) | <0.0001 | 0.67 | 0.66–0.68 |
| 60–69 | 605162 (39.41) | 59768 (35.6) | <0.0001 | 0.85 | 0.84–0.86 |
| 70–79 | 578433 (37.67) | 80209 (47.77) | <0.0001 | 1.51 | 1.50–1.53 |
| 80+ | 61622 (4.01) | 8639 (5.145) | <0.0001 | 1.30 | 1.27–1.33 |
| Primary Payer | |||||
| Cash/Self-Pay | 1880 (0.12) | 189 (0.11) | <0.0001 | 0.92 | 0.79–1.07 |
| Commercial/Private Insurance | 1035859 (67.46) | 107761 (64.18) | <0.0001 | 0.86 | 0.86–0.87 |
| Government | 26729 (1.74) | 2448 (1.46) | <0.0001 | 0.83 | 0.80–0.87 |
| Medicaid | 45980 (3) | 5033 (3) | 0.9431 | – | – |
| Medicare | 495698 (32.28) | 60685 (36.14) | <0.0001 | 1.19 | 1.17–1.20 |
| Unknown | 14731 (0.96) | 1807 (1.08) | <0.0001 | 1.12 | 1.07–1.18 |
| Service Location | |||||
| Clinic | 73 (0.005) | a | 0.0391 | 0.12 | 0.02–0.90 |
| Inpatient | 1090284 (71) | 132100 (78.67) | <0.0001 | 1.50 | 1.49–1.53 |
| Office | 4586 (0.3) | 518 (0.31) | 0.4833 | – | – |
| Outpatient | 512107 (33.35) | 42516 (25.32) | <0.0001 | 0.68 | 0.67–0.69 |
| Unknown | 4035 (0.26) | 417 (0.25) | 0.2719 | – | – |
| Charlson Score | |||||
| Zero | 615402 (40.08) | 37571 (22.38) | <0.0001 | 0.43 | 0.43–0.44 |
| One-Two | 621452 (40.47) | 63648 (37.91) | <0.0001 | 0.90 | 0.89–0.91 |
| Three-Four | 207895 (13.54) | 37168 (22.14) | <0.0001 | 1.81 | 1.79–1.84 |
| >5 | 90804 (5.91) | 29510 (17.57) | <0.0001 | 3.39 | 3.24–3.44 |
| Elixhauser Score | |||||
| Zero | 127407 (8.23) | 7467 (4.45) | <0.0001 | 0.51 | 0.50–0.53 |
| One - Four | 804086 (52.36) | 52628 (31.34) | <0.0001 | 0.41 | 0.41–0.42 |
| >5 | 604091 (39.34) | 107807 (64.2) | <0.0001 | 2.76 | 2.74–2.80 |
| Comorbidities | |||||
| Diabetes | 429043 (27.94) | 65105 (38.77) | <0.0001 | 1.63 | 1.62–1.65 |
| Obesity | 544790 (35.48) | 65355 (38.92) | <0.0001 | 1.16 | 1.15–1.17 |
| Tobacco Use | 338103 (22.02) | 45703 (27.22) | <0.0001 | 1.32 | 1.31–1.34 |
| Complication | Non-Cardiomyopathy (%) n = 1,535,586 | Cardiomyopathy (%) n = 167,911 | p-value | Odds Ratio (Study Cohort/Control) | Odds Ratio 95 % Confidence Interval |
| Respiratory Failure | 12908 (0.84) | 3421 (2.04) | <0.0001 | 2.45 | 2.36–2.55 |
| Urinary Tract Infection | 32866 (2.14) | 5432 (3.24) | <0.0001 | 1.53 | 1.48–1.57 |
| Postoperative Shock | 1421 (0.09) | 508 (0.30) | <0.0001 | 3.28 | 2.96–3.63 |
| Postoperative Infection | 8040 (0.52) | 1510 (0.9) | <0.0001 | 1.72 | 1.63–1.82 |
| DVT | 18321 (1.19) | 3033 (1.81) | <0.0001 | 1.52 | 1.47–1.58 |
| Pulmonary Embolism | 6391 (0.42) | 1220 (0.73) | <0.0001 | 1.75 | 1.65–1.86 |
| Disruption of Wound | 8724 (0.6) | 1539 (0.92) | <0.0001 | 1.62 | 1.53–1.71 |
| Revisions | 4269 (0.28) | 736 (0.44) | <0.0001 | 1.58 | 1.46–1.71 |
| 2 year Revisions | 29590 (1.93) | 4481 (2.67) | <0.0001 | 1.40 | 1.35–1.44 |
| 30-day Readmission | 68344 (4.45) | 13392 (7.97) | <0.0001 | 1.86 | 1.83–1.90 |
| 90-day Readmission | 89522 (5.83) | 17270 (10.29) | <0.0001 | 1.85 | 1.82–1.88 |
| AKI | 19609 (1.28) | 5425 (3.23) | <0.0001 | 2.58 | 2.50–2.66 |
| Acute Myocardial Infarction | 2643 (0.17) | 1199 (0.71) | <0.0001 | 4.17 | 3.90–4.47 |
| Cardiac Arrest | 516 (0.03) | 288 (0.17) | <0.0001 | 5.11 | 4.42–5.90 |
| Cardiac Arrhythmias | 88309 (5.75) | 27758 (16.53) | <0.0001 | 3.25 | 3.20–3.28 |
| Congestive Heart Failure | 19203 (1.25) | 14072 (8.38) | <0.0001 | 7.22 | 7.06–7.39 |
| Hematoma/Hemorrhage | 5222 (0.34) | 994 (0.59) | <0.0001 | 1.75 | 1.63–1.87 |
| Pneumonia | 10203 (0.66) | 2519 (1.5) | <0.0001 | 2.28 | 2.18–2.38 |
| Sepsis | 5571 (0.36) | 1395 (0.83) | <0.0001 | 2.30 | 2.17–2.44 |
| Periprosthetic Joint Infection | 5478 (0.36) | 1048 (0.62) | <0.0001 | 1.75 | 1.64–1.87 |
| Periprosthetic Dislocation | 111 (0.01) | 12 (0.01) | 0.9701 | – | – |
| Periprosthetic Mechanical Complication | 3348 (0.22) | 485 (0.29) | <0.0001 | 1.33 | 1.21–1.46 |
| Periprosthetic Fracture | 727 (0.05) | 114 (0.07) | <0.0001 | 1.43 | 1.18–1.75 |
| Stiffness | 87469 (5.7) | 6910 (4.12) | <0.0001 | 0.71 | 0.69–0.73 |
| Manipulation Under Anesthesia | 2477 (0.16) | 283 (0.17) | 0.5207 | – | – |
| 90-day Manipulation Under Anesthesia | 48447 (3.15) | 4238 (2.52) | <0.0001 | 0.79 | 0.77–0.82 |
| Superficial Incision Infection | 863 (0.06) | 117 (0.07) | 0.0290 | 1.24 | 1.02–1.50 |
| Deep Incision Infection | 185 (0.01) | 26 (0.02) | 0.2308 | – | – |
| Demographic | Non-Cardiomyopathy (%) n = 163,625 | Cardiomyopathy (%) n = 163,625 | p-value | Odds Ratio | 95 % Confidence Interval |
| Genders | |||||
| Male | 75510 (46.15) | 75510 (46.15) | 1 | – | – |
| Female | 88115 (53.85) | 88115 (53.85) | 1 | – | – |
| Age | |||||
| >20 | 12 (0.001) | 12 (0.01) | 1 | – | – |
| 20–39 | 248 (0.15) | 247 (0.15) | 0.9620 | – | – |
| 40–49 | 3398 (2.08) | 3400 (2.08) | 0.9804 | – | – |
| 50–59 | 23347 (14.27) | 23315 (14.25) | 0.8729 | – | – |
| 60–69 | 58677 (35.86) | 58516 (35.76) | 0.5572 | – | – |
| 70–79 | 78880 (48.21) | 78679 (48.08) | 0.4819 | – | – |
| 80+ | 8401 (5.13) | 8162 (4.99) | 0.0567 | – | – |
| Primary Payer | |||||
| Cash/Self-Pay | 210 (0.13) | 184 (0.11) | 0.1903 | – | – |
| Commercial/Private Insurance | 106862 (65.31) | 104845 (64.08) | <0.0001 | 0.95 | 0.93–0.96 |
| Government | 2701 (1.65) | 2390 (1.46) | <0.0001 | 0.88 | 0.84–0.93 |
| Medicaid | 5290 (3.23) | 4718 (2.88) | <0.0001 | 0.89 | 0.85–0.92 |
| Medicare | 58375 (35.68) | 59325 (36.26) | 0.0005 | 1.03 | 1.01–1.04 |
| Unknown | 1611 (0.99) | 1757 (1.07) | 0.0115 | 1.09 | 1.02–1.17 |
| Service Location | |||||
| Clinic | 11 (0.01) | a | 0.0217 | 0.09 | 0.01–0.70 |
| Inpatient | 111679 (68.25) | 129092 (78.9) | <0.0001 | 1.74 | 1.71–1.77 |
| Office | 448 (0.27) | 509 (0.31) | 0.0484 | 1.14 | 1.00–1.29 |
| Outpatient | 60289 (36.85) | 40936 (25.02) | <0.0001 | 0.57 | 0.56–0.58 |
| Unknown/Other | 451 (0.28) | 405 (0.25) | 0.1156 | 0.90 | 0.78–1.03 |
| Charlson Score | |||||
| Zero | 35871 (21.92) | 35175 (21.5) | 0.0032 | 0.98 | 0.96–0.99 |
| One-Two | 62890 (38.44) | 62738 (38.34) | 0.5848 | – | – |
| Three-Four | 37550 (22.95) | 37806 (23.11) | 0.2878 | – | – |
| >5 | 27299∗ (16.68) | 27889 (17.04) | 0.0058 | 1.03 | 1.01–1.05 |
| Elixhauser Score | |||||
| Zero | 7463 (4.56) | 7463 (4.56) | 1 | – | – |
| One - Four | 52520 (32.1) | 52520 (32.1) | 1 | – | – |
| >5 | 103639 (63.34) | 103639 (63.34) | 1 | – | – |
| Comorbidities | |||||
| Diabetes | 68859 (42.08) | 62542 (38.22) | <0.0001 | 0.85 | 0.84–0.86 |
| Obesity | 72189 (44.11) | 62053 (37.92) | <0.0001 | 0.78 | 0.76–0.79 |
| Tobacco Use | 51326 (31.36) | 43544 (26.61) | <0.0001 | 0.79 | 0.78–0.81 |
2.3 Statistical analysis
Data compilation was completed using the PearlDiver platform. Data analysis and visualization were conducted with Microsoft Excel (2025). Descriptive statistics were used to compile the patient data for the demographic comparisons. The subsequent comparisons consisted of unmatched and matched analyses. A 1:1 propensity-match algorithm using preoperative characteristics and comorbidities was conducted. Patients in the TKA, control group, and TKA with Cardiomyopathy group, study cohort, were matched based on age, sex, smoking status, diabetes, obesity status, Charlson Score, and Elixhauser Score using PearlDiver's matching algorithm. Chi-square analyses were used to compare categorical variables. A P-value of 0.05 was considered statistically significant for all tests. The odds ratio and the 95 % confidence intervals were conducted for variables with a statistically significant difference. The odds ratio was determined as the ratio of the incidence of the complication in the TKA with Cardiomyopathy group to the incidence in the TKA without Cardiomyopathy control group.
3 Results
A total of 1,695,610 patients who underwent TKA were identified with PearlDiver. The TKA group of patients without cardiomyopathy contained 1,528,494 patients, and the group of TKA patients with cardiomyopathy contained 167,116 patients.
3.1 Demographic data
The TKA patients with Cardiomyopathy group, the study cohort, had 1.5127 times more male patients at 46.45 %, than the control group with a percentage of 36.44 % (P < 0.0001) and 0.66times less females (P < 0.0001). The study cohort and control group both had more females than males who underwent TKA, with a percentage of 63.56 % and 53.55 %, respectively. TKA patients with Cardiomyopathy tended to have more patients in the higher age ranges of 70–79 and 80+, while the control had more patients in the younger age ranges of 20–39, 40–49, 50–59, and 60–69 (P < 0.0001). The number of patients in the control group with a primary payer of commercial/private insurance, government and cash was significantly more than the study cohort (P < 0.0001). On the other hand, the TKA Cardiomyopathy group consisted of more Medicare patients (P < 0.0001). These patients in the study cohort were 1.51 times more likely to receive the TKA as inpatients (P < 0.0001), while the control group was more likely to receive TKA in an outpatient setting (P < 0.0001). Regarding the Charlson score, TKA patients with Cardiomyopathy had a significantly higher number of patients in the 3–4 and >5 Charlson score groups, while the control group had more patients in the 0 and 1–2 score groups (P < 0.0001). Similar trends were observed with the Elixhauser Score. The study cohort had more patients with a score greater than 5, while the control had more patients in the 0 and 1–4 groups (P < 0.0001). Regarding diabetes, obesity, and tobacco use comorbidities, the TKA patients with Cardiomyopathy had significantly more patients in each group compared to the control (P < 0.0001) (Table 1).
3.2 Unmatched postoperative outcomes analysis
In the comparison of the postoperative complications, there was a significantly higher incidence among the TKA patients with Cardiomyopathy than the control group for each complication except wound complications (Table 2). Some of the most notable differences were an increase incidence of congestive heart failure (8.38 %, P < 0.001), cardiac arrest (0.17 %, P < 0.001), acute myocardial infarction (0.71 %, P < 0.0001), cardiac arrhythmias (16.53 %, P < 0.001), postoperative shock (0.30 % P < 0.001), acute kidney injury (3.23 %, P < 0.0001), respiratory failure (3.23 %, P < 0.0001), sepsis (0.83 %, P < 0.0001), pneumonia (1.5 %, P < 0.0001) deep vein thrombosis (1.81 %, P < 0.0001), and hemorrhage (0.59 %, P < 0.0001) in the study cohort compared to the incidence of congestive heart failure (1.25 %), cardiac arrest (0.03 %), acute myocardial infarction (0.17 %), cardiac arrhythmias (5.75 %), postoperative shock (0.09 %), acute kidney injury (1.28 %) and respiratory failure (0.84 %), sepsis (0.36 %), pneumonia (0.66 %) deep vein thrombosis (1.19 %), and hemorrhage (0.34 %) in the control group. The number of readmissions within 30 days in the study cohort (7.97 %) was significantly higher than in the control group (4.45 %, P < 0.0001). The number of readmissions within 90 days in the study cohort (10.29 %, P < 0.0001) was also significantly higher than in the control group (5.83 %, P < 0.0001). The study cohort had a significantly higher number of patients who received revisions within 30 days (0.44 %, P < 0.0001) compared to the control group (0.28 %). Regarding revisions within two years, the study cohort also had a significantly higher incidence (2.67 %) compared to the control group (1.93 %, P < 0.0001) (Table 2). For the local complications within 30 days, there was a significant increase incidence in the study cohort of periprosthetic joint infection (0.62 %, P < 0.0001), mechanical complication (0.29 %, P < 0.0001), fracture (0.07 %, P < 0.0001), stiffness (4.12 %, P < 0.0001), superficial incision infection (0.07 %, P < 0.0001) and disruption of wound (0.92 %, P < 0.0001) compared to periprosthetic joint infection (0.36 %), mechanical complication (0.22 %), fracture (0.05 %), stiffness (5.7 %), superficial incision infection (0.06 %) and disruption of wound (0.6 %) in the control.
3.3 Matched postoperative outcomes analysis
The 1:1 propensity match algorithm matched a total of 163,625 patients in each group, study cohort, and control (Table 4). In the comparison of the postoperative complications, there was a significantly higher incidence among the TKA patients with cardiomyopathy than the control group for each complication except periprosthetic dislocation and deep incision infection (Table 4). Some of the most notable differences were an increase incidence of congestive heart failure (8.01 %, P < 0.001), cardiac arrest (0.16 %, P < 0.001), acute myocardial infarction (0.7 %, P < 0.0001), cardiac arrhythmias (16.24 %, P < 0.001), postoperative shock (0.29 % P < 0.001), acute kidney injury (3.09 %, P < 0.0001), respiratory failure (1.95 %, P < 0.0001), sepsis (0.79 %, P < 0.0001), pneumonia (1.46 %, P < 0.0001) deep vein thrombosis (1.8 %, P < 0.0001), and hemorrhage (9.58 %, P < 0.0001) in the study cohort compared to the incidence of congestive heart failure (2.75 %), cardiac arrest (0.05 %), acute myocardial infarction (0.29 %), cardiac arrhythmias (8.75 %), postoperative shock (0.15 %), acute kidney injury (2.29 %), respiratory failure (1.46 %), sepsis (0.58 %), pneumonia (1.01 %) deep vein thrombosis (1.44 %), and hemorrhage (0.45 %) in the control group. The number of readmissions within 30 days in the study cohort (7.83 %) was significantly higher than the control group (5.59 %, P < 0.0001). The number of readmissions within 90 days in the study cohort (10.08 %, P < 0.0001) was also significantly higher than the control group (7.36 %, P < 0.0001). The study cohort had a significantly higher number of patients who received revisions within 30 days (0.42 %, P = 0.0016) compared to the control group (0.33 %). Regarding revisions within two years, the study cohort also had a significantly higher incidence (2.61 %) compared to the control group (2.15 %, P < 0.0001) (Table 4). For the local complications within 30 days, there was a significant increase incidence in the study cohort of periprosthetic joint infection (0.58 %, P = 0.0397), mechanical complication (0.28 %, P = 0.0213), disruption of wound (0.89 %, P < 0.0001) and manipulation under anesthesia (0.17 %, P = 0.0012) compared to periprosthetic joint infection (0.52 %), mechanical complication (0.24 %), disruption of wound (0.76 %) and manipulation under anesthesia (0.12 %) in the control. However, there was an increased incidence of stiffness (5.73 %, P < 0.0001) and superficial incision infection (0.09 %, P < 0.0001) in the control group compared to stiffness (4.01 %) and superficial incision infection (0.06 %) in the study cohort.
| Complication | Non-Cardiomyopathy (%) n = 163,625 | Cardiomyopathy (%) n = 163,625 | p-value | Odds Ratio (Study Cohort/Control) | Odds Ratio 95 % Confidence Interval |
| Respiratory Failure | 2382 (1.46) | 3193 (1.95) | <0.0001 | 1.35 | 1.28–1.42 |
| Urinary Tract Infection | 4323 (2.64) | 5194 (3.17) | <0.0001 | 1.21 | 1.16–1.26 |
| Postoperative Shock | 238 (0.15) | 474 (0.29) | <0.0001 | 1.99 | 1.71–2.33 |
| Postoperative Infection | 1094 (0.67) | 1444 (0.88) | <0.0001 | 1.32 | 1.22–1.43 |
| DVT | 2362 (1.44) | 2938 (1.8) | <0.0001 | 1.25 | 1.18–1.32 |
| Pulmonary Embolism | 764 (0.47) | 1188 (0.73) | <0.0001 | 1.56 | 1.42–1.71 |
| Disruption of Wound | 1246 (0.76) | 1449 (0.89) | <0.0001 | 1.16 | 1.08–1.26 |
| Revisions | 551 (0.33) | 693 (0.42) | <0.0001 | 1.26 | 1.13–1.41 |
| 2-year Revisions | 3525 (2.15) | 4264 (2.61) | <0.0001 | 1.22 | 1.16–1.27 |
| 30-day Readmission | 9150 (5.59) | 12814 (7.83) | <0.0001 | 1.43 | 1.40–1.47 |
| 90-day Readmission | 12039 (7.36) | 16491 (10.08) | <0.0001 | 1.41 | 1.38–1.45 |
| AKI | 3750 (2.29) | 5048 (3.09) | <0.0001 | 1.36 | 1.30–1.42 |
| Acute Myocardial Infarction | 469 (0.29) | 1146 (0.7) | <0.0001 | 2.45 | 2.20–2.73 |
| Cardiac Arrest | 81 (0.05) | 266 (0.16) | <0.0001 | 3.29 | 2.56–4.22 |
| Cardiac Arrhythmias | 14322 (8.75) | 26566 (16.24) | <0.0001 | 2.02 | 1.98–2.06 |
| Congestive Heart Failure | 4506 (2.75) | 13109 (8.01) | <0.0001 | 3.08 | 2.97–3.18 |
| Hematoma/Hemorrhage | 739 (0.45) | 951 (9.58) | <0.0001 | 1.29 | 1.17–1.42 |
| Pneumonia | 1656 (1.01) | 2392 (1.46) | <0.0001 | 1.45 | 1.36–1.55 |
| Sepsis | 944 (0.58) | 1290 (0.79) | <0.0001 | 1.37 | 1.26–1.49 |
| Periprosthetic Joint Infection | 855 (0.52) | 942 (0.58) | 0.0397 | 1.10 | 1.00–1.21 |
| Periprosthetic Dislocation | 13 (0.01) | 12 (0.01) | 0.8415 | – | – |
| Periprosthetic Mechanical Complication | 390 (0.24) | 457 (0.28) | 0.0213 | 1.17 | 1.02–1.34 |
| Periprosthetic Fracture | 113 (0.069) | 103 (0.06) | 0.4963 | – | – |
| Stiffness | 9372 (5.73) | 6669 (4.01) | <0.0001 | 0.70 | 0.68–0.72 |
| Manipulation Under Anesthesia | 203 (0.12) | 274 (0.17) | 0.0012 | 1.35 | 1.13–1.62 |
| 90-day Manipulation Under Anesthesia | 4274 (2.61) | 4131 (2.52) | 0.1141 | – | – |
| Superficial Incision Infection | 144 (0.09) | 102 (0.06) | 0.0077 | 0.71 | 0.55–0.91 |
| Deep Incision Infection | 27 (0.02) | 25 (0.02) | 0.7815 | – | – |
4 Discussion
This study provides a comprehensive analysis of the impact of cardiomyopathy on postoperative outcomes in patients undergoing TKA. Our findings indicate an increased risk of 30-day postoperative complication rates in patients with cardiomyopathy, ranging from adverse cardiopulmonary events, infections, mechanical complications, and thromboembolic events. They also have an increased risk of 30-day and 90-readmissions, 30-day and 2-year revisions. These results suggest that cardiomyopathy is a critical risk factor for adverse postoperative outcomes following TKA.
While research regarding the effect of cardiomyopathy on TKA is sparse, current literature notes that patients with cardiovascular disease are at an increased risk of complications. Okpara et al. found that patients with pre-existing cardiovascular diseases, such as coronary artery disease, congestive heart failure, valvular dysfunction, or arrhythmias, display higher rates of complications following TKA. It was noted these negative effects included postoperative myocardial infarction, infection, acute kidney injury, need for transfusions, arrhythmia, and increased change of thromboembolic events.18 Singh et al. examined cardiac and thromboembolic complications in patients undergoing TKA. They observed a significantly increased rate of 90-day cardiac and thromboembolic complications in patients with a prior history of cardiac/thromboembolic disease.3 Similarly, Elsiwy et al. examined risk factors associated with cardiac complications after TKA. In their study, they also noted postoperative cardiac complications following TKA were observed more frequently in patients with a prior history of cardiac disease.19 Our findings corroborate the data in these studies, with a more calculated etiology of cardiac disease, cardiomyopathy, instead of the generally all-encompassing diagnosis of cardiac disease.
Chokshi et al. examined the risk factors of cardiac events following TKA and noted an increased rate of postoperative heart failure and troponin elevations.20 Myocardial infarction, one of the most feared adverse effects of TKA, has been identifiably increased in patients with prior CHF, CAD, valvular dysfunction, and arrhythmia, as noted in Basilico et al. and Menendez et al.21,22 Additionally, Shah et al. found that independent risk factors of cardiac events following TKA include prior cardiac diseases.23 The same can be applied to patients with cardiomyopathy, as our findings demonstrated similar results of increased myocardial infarction, cardiac arrest, arrhythmias, and congestive heart failure.
In addition to adverse cardiac events, Kotzur et al. studied the rates of readmissions within 30 days in patients with arrhythmias. That study noted a greater rate of readmissions and reoperations within 30 days in patients with a prior diagnosis of cardiac arrhythmias.24 While many etiologies of cardiomyopathy may manifest as an arrhythmia, our findings demonstrated an increased rate of readmissions and revisions in patients with cardiomyopathy. This note corroborates the conclusions of Kotzur et al. but also suggests cardiomyopathy is an independent risk factor.
Local complications of TKA in patients with cardiac comorbidities, such as periprosthetic joint infection (PJI), have been noted in the literature as well. Rodriguez-Merchan et al. observed congestive heart failure as an independent risk factor for PJI.25 Post-atrial fibrillation and myocardial infarction, which were significant adverse findings in this study, were also determined to be independent risk factors of PJI as well by Pulido et al.26 Our results demonstrate a similar trend of increased PJI rates in patients with cardiomyopathy following TKA.
Mesarick et al. further noted an increased rate of periprosthetic mechanic complications in patients who previously underwent heart valve surgery.27 Similar patients who underwent heart transplants in Leonard et al. displayed an increased risk of manipulation under anesthesia.28 While these are different etiologies of cardiac dysfunction, our study showed similar findings of increased mechanical complications and increase risk of MUA in cardiomyopathy patients in this study. Additionally, Curtis et al. identified heart failure as a significant risk factor for wound dehiscence, while Sandy-Hodgetts et al. reported a similar association with cardiovascular disease.29,30 Our findings of increased disruption of wounds in cardiomyopathy patients corroborate these similar studies. Regarding the revision risk, Jasper et al. noted hypertension, coronary disease, and cardiovascular disease all increased the risk of revision in TKA.31 Our findings demonstrated similar trends in patients with cardiomyopathy, thus supporting the notion that cardiomyopathy significantly increases the revision risk.
The limitations of our study are prototypical to retrospective database studies and with those that use ICD and CPT codes for data retrieval. While these codes provide abundant data, there is a risk of coding errors and inconsistencies between specific diagnoses, diseases, complications, and operations that can lead to misrepresented data. This includes coding entries that were omitted. Differences in code, such as over-coding or underreporting, can vary from institution to institution as well. ICD and CPT code findings also do not include granular clinical data, such as a patient's complete medical history, individual laboratory values, imaging findings, disease severity, and function status. Furthermore, these codes do not allow for adjustments for surgeon and hospital variabilities in treatment that may be present. However, due to the large sample size of 163,625 patients in the matched comparison, it is reasonable to conclude that this data is representative of the general United States population.
Future research could focus on post-operative complication rates between the different etiologies of cardiomyopathy, such as dilated, restrictive, and hypertrophic cardiomyopathy or infectious and inflammatory conditions. Additional studies could also investigate the long-term outcomes of TKA in these patients, as this study looks at 30-day complication rates for the most part.
In conclusion, surgeons performing TKA on patients with cardiomyopathy should consider the elevated risk of postsurgical medical complications, revisions, and readmission rates when conducting preoperative patient selections and risk assessments.
Guardian/patient consent
This research contained de-identified patient data, therefore consent was not obtained.
Contributions
Hayden Flume helped with the conceptualization, methodology, software, formal analysis, investigation, data curation, writing - original draft writing – review & editing, visualization, and project administration. Clarissa Meza helped with validation and original writing – review & editing. Megan Sorich helped with validation and supervision. Senthil Sambandam helped with resources, data acquisition, validation, supervision and original writing – review & editing.
Ethics statement
This study used de-identified patient data from a national database. As such, institutional review board approval and informed consent were not required. This study was conducted in accordance with HIPPA and the ethical standards of the Helsinki Declaration.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
References
- The dramatic increase in total knee replacement utilization rates in the United States cannot be fully explained by growth in population size and the obesity epidemic. J Bone Jt Surg Am Vol. 2012;94(3):201-207.
- [Google Scholar]
- Temporal trends in comorbidity in adult elective hip and knee arthroplasty patients in England: a national population-based cohort Study from the national joint registry. The Bone & Joint Journal. 2022;104-B(9):1052-1059.
- [Google Scholar]
- Cardiac and thromboembolic complications and mortality in patients undergoing total hip and total knee arthroplasty. Ann Rheum Dis. 2011;70(12):2082-2088.
- [Google Scholar]
- The public health burden of cardiomyopathies: insights from a nationwide inpatient Study. J Clin Med. 2020;9(4):920.
- [Google Scholar]
- Classification of the cardiomyopathies: a position statement from the European Society of Cardiology Working Group on myocardial and pericardial diseases. Eur Heart J. 2008;29(2):270-276.
- [Google Scholar]
- Contemporary definitions and classification of the cardiomyopathies: an American heart Association scientific statement. Circulation. 2006;113(14):1807-1816.
- [Google Scholar]
- Proposal for a revised definition of dilated cardiomyopathy, hypokinetic non-dilated cardiomyopathy, and its implications for clinical practice. Eur Heart J. 2016;37(23):1850-1858.
- [Google Scholar]
- Cardiomyopathies: evolution of pathogenesis concepts and potential for new therapies. World J Cardiol. 2014;6(6):478-494.
- [Google Scholar]
- Alcoholic cardiomyopathy: incidence, clinical characteristics, and pathophysiology. Chest. 2002;121(5):1638-1650.
- [Google Scholar]
- Cardiovascular disease in total knee arthroplasty: an analysis of Hospital outcomes, complications, and mortality. Clin Orthop Surg. 2024;16(2):265-274.
- [Google Scholar]
- Risk factors associated with cardiac complication after total joint arthroplasty of the hip and knee: a systematic review. J Orthop Surg Res. 2019;14(1):15.
- [Google Scholar]
- Risk factors associated with postoperative cardiac events following total hip and knee arthroplasty. J Arthroplast. 2024;39(3):825-830.
- [Google Scholar]
- A nationwide analysis of risk factors for In-Hospital myocardial infarction after total joint arthroplasty. Int Orthop. 2015;39(4):777-786.
- [Google Scholar]
- Risk factors for cardiovascular complications following total joint replacement surgery. Arthritis Rheum. 2008;58(7):1915-1920.
- [Google Scholar]
- Myocardial infarction risk in arthroplasty Vs arthroscopy: how much does procedure type matter? J Arthroplast. 2017;32(1):246-251.
- [Google Scholar]
- The impact of cardiac Arrhythmias on total knee arthroplasty outcomes. J Arthroplast. 2024;39(9)
- [Google Scholar]
- Risk factors for periprosthetic joint infection after primary total knee arthroplasty. J Clin Med. 2022;11(20):6128.
- [Google Scholar]
- Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466(7):1710-1715.
- [Google Scholar]
- Cardiac interventions on total knee arthroplasty: a national inpatient sample-based analysis. Arch Orthop Trauma Surg. 2024;144:2229-2238.
- [Google Scholar]
- Outcomes of total hip and knee arthroplasty after cardiac transplantation. J Arthroplast. 2012;27(6):889-894.
- [Google Scholar]
- Perioperative outcomes and complications in patients with heart failure following total knee arthroplasty. J Arthroplast. 2018;33(1):36-40.
- [Google Scholar]
- Determining risk factors for surgical wound dehiscence: a literature review. Int Wound J. 2015;12(3):265-275.
- [Google Scholar]
- Risk factors for revision of total knee arthroplasty: a scoping review. BMC Muscoskelet Disord. 2016;17:182.
- [Google Scholar]