A new international study published in JMIR Perioperative Medicine calls for more rigorous monitoring of patients for the risk of postoperative complications after orthopedic surgeries, particularly myocardial injury after noncardiac surgery (MINS), major bleeding, and sepsis.
“Association Between Complications and Death Within 30 Days After Orthopedic Surgery: Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Substudy,” begins with the perspective that “the contemporary causes of postoperative mortality in orthopedic surgery are not well characterized.” It then works to “describe the epidemiology of postoperative complications among adult patients who underwent orthopedic surgery and inform their relationships with 30-day mortality.”
VISION was a prospective cohort study published in the late 2010s that involved 40,004 adult patients who underwent noncardiac surgery across 28 centers in 14 countries. The new study examines the subset of 8,385 patients in the VISION study who underwent orthopedic surgery. The researchers sought to “determine time-dependent associations between various surgical complications and 30-day postoperative mortality,” with analyses adjusted for “preoperative and surgical variables.”
Of the 8,385 patients in the VISION study who underwent orthopedic surgery, 132 (1.6%) died within 30 days postoperatively. The researchers found that 63.6% of the deaths “occurred in hospital during the index hospitalization,” while 36.4% occurred post-discharge.
The researchers examined the incidence of those deaths across orthopedic surgery subcategories: 13.6% of patients who underwent above-knee amputation, 3.9% who underwent internal fixation of femur, 3.6% who underwent lower leg amputation, 1.7% who underwent major hip or pelvic surgery, 0.6% who underwent major spine surgery, and 0.2% who underwent knee arthroplasty.
In adjusted analyses, researchers associated six postoperative complications with the deaths: MINS, major bleeding, infection without sepsis, sepsis, stroke, and atrial fibrillation. They proceeded to determine the “greatest attributable fractions of postoperative mortality (i.e., proportion of deaths in the cohort that can be attributed to each complication, if causality were established)” were from MINS, major bleeding, and sepsis.
The researchers also noted that urgent or emergent surgeries carried more than double the risk of 30-day mortality compared to planned, nonemergent procedures.
They concluded that their findings “highlight areas for further study to mitigate perioperative mortality in orthopedic surgery. MINS demonstrated the highest attributable fraction for mortality (20.6%), emphasizing the importance of appropriate MINS screening, diagnosis, and management”—especially since MINS is a “silent” heart injury that the researchers say demands far more rigorous monitoring than is currently standard practice.
Noting that traditional risk-scoring systems often overlook massive variations between different types of orthopedic surgeries, the researchers believe their study demonstrates that specialty-specific, procedure-specific data is crucial to properly stratify patient risk and allocate higher-level postoperative care such as intensive cardiac monitoring or telemetry.
