Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

What Is the Timing of General Health Adverse Events That Occur After Total Joint Arthroplasty?

Daniel D. Bohl MD, MPH, Nathaniel T. Ondeck BS, Bryce A. Basques MD, Brett R. Levine MD, Jonathan N. Grauer MD



Despite extensive research regarding risk factors for adverse events after total joint arthroplasty (TJA), there are few publications describing the timing at which such adverse events occur.


(1) On which postoperative day do certain adverse events occur? (2) What adverse events occur earlier after TKA than after THA? (3) For each adverse event, what proportion occurred after hospital discharge?


We screened the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to identify all patients undergoing primary THA and primary TKA between 2005 and 2013, resulting in a study population of 124,657 patients evaluated as part of this retrospective database analysis. For each of eight different adverse events, the median postoperative day of diagnosis, interquartile range for day of diagnosis, and middle 80% for day of diagnosis were determined. Multivariate Cox proportional hazards modeling was used to test whether there is a difference of timing for each adverse event as stratified by TKA or THA. The proportion of adverse events occurring after versus before discharge was also calculated.


The median day of diagnosis (and interquartile range; middle 80%) for stroke was 2 (1–10; 1–19), myocardial infarction 3 (2–6; 1–15), pulmonary embolism 3 (2–7; 1–19), pneumonia 4 (2–9; 2–17), deep vein thrombosis 6 (3–14; 2–23), urinary tract infection 8 (3–16; 2–24), sepsis 10 (5–19; 2–24), and surgical site infection 17 (11–23; 6–28). For the later occurring adverse events (surgical site infection, sepsis), the rate of occurrence remained high at the end of the 30-day postoperative period. Timing was earlier in patients undergoing TKA for pulmonary embolism (day 3 [interquartile range 2–6] versus 5 [3–17], p < 0.001) and deep vein thrombosis (day 5 [2–11] versus 13 [6–22], p < 0.001). The proportion of events occurring after discharge for myocardial infarction was 97 of 283 (34%), stroke 42 of 118 (36%), pulmonary embolism 223 of 625 (36%), pneumonia 171 of 426 (40%), deep vein thrombosis 576 of 956 (60%), urinary tract infection 958 of 1406 (68%), sepsis 284 of 416 (68%), and surgical site infection 1147 of 1212 (95%).


As lengths of hospital stay after TJA continue to decrease, our findings suggest that caution is in order because several acute and immediately life-threatening findings, including myocardial infarction and pulmonary embolism, might occur after discharge. Furthermore, the timing of surgical site infection and sepsis suggests that even the 30-day followup afforded by the ACS-NSQIP may not be sufficient to study the latest occurring adverse events. Additionally, both pulmonary embolism and deep vein thrombosis tend to occur earlier after TKA than THA, and this should guide clinical surveillance efforts in patients undergoing those procedures. These findings also indicate that inpatient-only databases (such as the Nationwide Inpatient Sample) may fail to capture a very large proportion of postoperative adverse events, weakening the conclusions of many published studies using those databases.

Level of Evidence

Level III, therapeutic study.

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