Child-Pugh Class B or C Liver Disease Increases the Risk of Early Mortality in Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty Regardless of Treatment Status

Abstract

Background Patients with hepatitis C virus (HCV) undergoing primary elective total joint arthroplasty (TJA) are at increased risk of postoperative complications. Patients with chronic liver disease and cirrhosis, specifically Child-Pugh Class B and C, who are undergoing general surgery have high 2-year mortality risks, approaching 60% to 80%. However, the role of Child-Pugh and Model for End-Stage Liver Disease classifications of liver status in predicting survivorship among patients with HCV undergoing elective arthroplasty has not been elucidated. Question/purpose What factors are independently associated with early mortality (< 2 years) in patients with HCV undergoing arthroplasty? Methods We performed a retrospective study at three tertiary academic medical centers and identified patients with HCV undergoing primary elective TJA between January 2005 and December 2019. Patients who underwent revision TJA and simultaneous primary TJA were excluded. A total of 226 patients were eligible for inclusion in the study. A further 25% (57) were excluded because they were lost to follow-up before the minimum study requirement of 2 years of follow-up or had incomplete datasets. After the inclusion and exclusion criteria were applied, the final cohort consisted of 75% (169 of 226) of the initial patient population eligible for analysis. The mean follow-up duration was 53 ± 29 months. We compared confounding variables for mortality between patients with early mortality (16 patients) and surviving patients (153 patients), including comorbidities, HCV and liver characteristics, HCV treatment, and postoperative medical and surgical complications. Patients with early postoperative mortality were more likely to have an associated advanced Child-Pugh classification and comorbidities including peripheral vascular disease, end-stage renal disease, heart failure, and chronic obstructive pulmonary disease. However, both groups had similar 90-day and 1-year medical complication risks including myocardial infarction, stroke, pulmonary embolism, and reoperations for periprosthetic joint infection and mechanical failure. A multivariable regression analysis was performed to identify independent factors associated with early mortality, incorporating all significant variables with p < 0.05 present in the univariate analysis. Results After accounting for significant variables in the univariate analysis such as peripheral vascular disease, end-stage renal disease, heart failure, chronic obstructive pulmonary disease, and liver fibrosis staging, Child-Pugh Class B or C classification was found to be the sole factor independently associated with increased odds of early (within 2 years) mortality in patients with HCV undergoing elective TJA (adjusted odds ratio 29 [95% confidence interval 5 to 174]; p < 0.001). The risk of early mortality in patients with Child-Pugh Class B or C was 64% (seven of 11) compared with 6% (nine of 158) in patients with Child-Pugh Class A (p < 0.001). Conclusion Patients with HCV and a Child-Pugh Class B or C at the time of elective TJA had substantially increased odds of death, regardless of liver function, cirrhosis, age, Model for End-Stage Liver Disease level, HCV treatment, and viral load status. This is similar to the risk of early mortality observed in patients with chronic liver disease undergoing abdominal and cardiac surgery. Surgeons should avoid these major elective procedures in patients with Child-Pugh Class B or C whenever possible. For patients who feel their arthritic symptoms and pain are unbearable, surgeons need to be clear that the risk of death is considerably elevated. Level of Evidence Level III, therapeutic study.

CORR Insights®: Child-Pugh Class B or C Liver Disease Increases the Risk of Early Mortality in Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty Regardless of Treatment Status

“…Similarly, patients with cirrhosis are at risk of complications after arthroplasty [10, 13]. The current study [2] does not clarify whether these patients should expect to benefit from arthroplasty as much as patients without cirrhosis.…”

“…Sustained negative viral load is linked to minimizing postoperative mechanical complications, particularly periprosthetic joint infection [4, 12]. The authors of an article in this month’s Clinical Orthopaedics and Related Research ® [2] earlier published a multicenter study finding that patients treated with antiviral therapy before arthroplasty were less likely to experience periprosthetic joint infection at 90 days and 1 year after surgery [3]. Because HCV is a prevalent and important pathogen, this information can help surgeons to reduce the risk of serious complications in a large group of patients.…”

“…Although periprosthetic joint infection is very important, death after surgery is obviously even more so. The authors of a study in this month’s CORR ® [2] found only one study that investigated postsurgical mortality in a mixed population of patients (those having orthopaedic, cardiovascular, and digestive surgery) who had the diagnosis of cirrhosis [14]. Patients undergoing orthopaedic surgery were only a small minority of patients in that study (14% subset of the 107 patients studied), and even that group was a mixed bag of elective and emergency procedures of the upper and lower extremities.…”

“…Patients undergoing orthopaedic surgery were only a small minority of patients in that study (14% subset of the 107 patients studied), and even that group was a mixed bag of elective and emergency procedures of the upper and lower extremities. Having more specific information on this topic would help surgeons to counsel patients fairly about the risks and benefits of elective total joint arthroplasty (TJA) in the setting of potentially severe liver disease; before the paper by Cichos et al [2], the association between liver cirrhosis of increasing severity (according to the Child-Pugh classification) and death after arthroplasty has not been well-described.…”

“…Cichos et al [2] determined that among patients with HCV undergoing elective TJA, more-severe liver damage (Child-Pugh Class B or C) was the sole factor that was independently associated with an increased odds of death shortly after surgery. The authors point out that postoperative mortality in patients with HCV undergoing general surgery has been well correlated with the severity of liver disease, as represented by the Child-Pugh classification or the Model for End-Stage Liver Disease score.…”