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Trends of Inhospital Mortality After Inpatient Elective Total Hip and Knee Arthroplasty: A 2016 to 2023
Periklis Giannakis1, Juliet E Rowe2, Renee Ren3
1Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York; Sports Medicine Institute, Hospital for Special Surgery, New York, New York; Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York.
Background:
Utilization of inpatient total hip arthroplasty and total knee arthroplasty (THA and TKA) has surged in older, more comorbid patients, but the impact of this shift on inhospital mortality remains unclear. Using a United States database, we described inhospital mortality trends of inpatient THA and TKA.
Methods:
This retrospective analysis (2016 to 2023) included adults undergoing inpatient elective THA and TKA. We described inhospital mortality rate trends. We then focused only on patients who experienced inhospital mortality and described patient, health care, hospital, and complication profile trends.
Results:
Mortality rates tripled for 549,236 inpatient THAs (2016 to 2017: 0.04% versus 2022 to 2023: 0.13%, P < 0.001) and increased for 840,991 inpatient TKAs (2016 to 2017: 0.03% versus 2022 to 2023: 0.05%, P = 0.006). Patient characteristics among those who died were stable. For both procedures, the inflation-adjusted cost of mortality-associated hospitalizations increased (thousands of United States Dollars; THA, 2016 to 2017: 33.1 [19.3 to 52.2] versus 2022 to 2023: 42.2 [31.1 to 56.5]; P = 0.026 and TKA, 2016 to 2017: 29.6 [19.4 to 46.5] versus 2022 to 2023: 33.1 [20.9 to 57.8]; P < 0.001). The proportion of mortality events decreased in high-case volume hospitals (THA, 2016 to 2017: 21.7% versus 2022 to 2023: 7.0%; P = 0.0015 and TKA, 2016 to 2017: 27.0% versus 2022 to 2023: 6.9%; P < 0.01). Complication profiles remained consistent, with respiratory failure, acute kidney injury, arrhythmia, and electrolyte disorders being the most common.
Conclusions:
Although mortality after inpatient THA and TKA remains very low, we observed increasing trends for both procedures. These trends may reflect greater utilization in older, more comorbid patients, alongside the transition of younger, healthier patients to outpatient settings. Importantly, mortality shifted from high-volume to low-volume hospitals; combined with rising costs, this may signal widening disparities in experience, protocols, and resources between centers.