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Joint replacement surgery riskier at hospitals with low surgical volume

Greater risk of blood clots and mortality following hip or knee arthroplasty

Patients who undergo elective total hip or total knee arthroplasty at hospitals with lower surgical volume had a higher risk of venous thromboembolism and mortality following the procedure. The complications following joint replacement surgery at low-volume sites may be reduced by modifying systems and procedures used before and after surgery according to the findings published today in Arthritis & Rheumatism, a peer-reviewed journal of the American College of Rheumatology (ACR).

The ACR estimates that 27 million Americans over the age of 25 have doctor-diagnosed osteoarthritis and another 1.3 million US adults suffer with rheumatoid arthritis. For patients with end-stage hip and knee arthritis, total hip and knee arthroplasty are highly successful surgical interventions that offer patients significant improvement in pain, function and health-related quality of life. According to the Centers for Disease Control and Prevention (CDC) National Hospital Discharge Survey, roughly 230,000 total hip replacements and 543,000 total knee replacements were performed in the U.S. in 2007.

The current study explored the relationship between hospital procedure volume and surgical outcomes following primary total hip or total knee replacements. "With the large number of elective arthroplasty in the U.S, it is important to understand the impact of peri- and post-operative medical complications on the success of joint replacement surgery," said lead author Jasvinder Singh, MD, MPH of the University of Alabama. "Possible cardiac complications, blood clots, or infections increase patient morbidity and mortality risk, which can lead to higher health care utilization and costs."

Researchers used the Pennsylvania Health Care Cost Containment Council database to identify the number of patients who underwent total hip replacement (n=10,187) and total knee replacement (n=19,418) surgery in 2002 in the state. The mean age of patients in both groups was 69 years, and men comprised 43% of the total hip replacement cohort and 35% of the total knee replacement group. Hospital volume was categorized by less than 25 surgeries, 26-100, 101-200 (low-volume hospitals), and greater than 200 surgeries (high-volume hospitals) performed annually.

The findings show that patients who had primary total hip arthroplasty at low-volume hospitals were more likely to develop a pulmonary embolism (within 30 days of surgery) than those who had surgery at a high-volume hospital. One-year mortality was also higher for patients having total hip replacements at low-volume hospitals.

Researchers found that for total knee arthroplasty, patients age 65 and older had significantly higher odds for one-year mortality when surgeries were performed at low-volume hospitals compared to higher volume hospitals.

The authors theorize that the causes of complications at low-volume hospitals could be connected to hospital procedures and peri- and post-operative care processes. One example cited is differences in the selection of the best medication and device used to prevent blood clots following elective joint replacement surgery. The authors also suggest that the outcome of surgery is impacted by time of initiation and cessation of the clot prevention therapy. Dr. Singh concluded, "Further studies are needed to investigate whether the underlying reasons for poor surgical outcomes at low-volume hospitals are modifiable and which interventions may reduce complications for patients at these facilities."

This study is published in Arthritis & Rheumatism. Media wishing to receive a PDF of the article may contact

Full citation: "Hospital Volume and Surgical Outcomes after Elective Hip/Knee Arthroplasty: A Risk Adjusted Analysis of a Large Regional Database." Jasvinder A. Singh, C. Kent Kwoh, Robert M. Boudreau, Gwo-Chin Lee, Said A. Ibrahim.Arthritis & Rheumatism; Published Online: June 7, 2011 (DOI: 10.1002/art.30390).

About the Journal

Arthritis & Rheumatism is an official journal of the American College of Rheumatology (ACR) and the Association of Rheumatology Health Professionals (ARHP), a division of the College, and covers all aspects of inflammatory disease. The American College of Rheumatology ( is the professional organization who share a dedication to healing, preventing disability, and curing the more than 100 types of arthritis and related disabling and sometimes fatal disorders of the joints, muscles, and bones. Members include practicing physicians, research scientists, nurses, physical and occupational therapists, psychologists, and social workers. For details, please visit

About Wiley-Blackwell

Wiley-Blackwell is the international scientific, technical, medical, and scholarly publishing business of John Wiley & Sons, with strengths in every major academic and professional field and partnerships with many of the world's leading societies. Wiley-Blackwell publishes nearly 1,500 peer-reviewed journals and 1,500+ new books annually in print and online, as well as databases, major reference works and laboratory protocols. For more information, please visit or our new online platform, Wiley Online Library (, one of the world's most extensive multidisciplinary collections of online resources, covering life, health, social and physical sciences, and humanities.

Dawn Peters | EurekAlert!
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