Increased Complication Rates After Hip and Knee Arthroplasty in Patients With Cirrhosis of the Liver

Background Risk stratification is critical in patients with cirrhosis undergoing THAs and TKAs, as they may be more likely to have serious medical and surgical complications. As opposed to the Child-Pugh scoring system, which has limited use for orthopaedic surgeons inexperienced in assessing ascites and hepatic encephalopathy, the Model for End-stage Liver Disease (MELD) is an easily calculated, validated scoring system for severity of liver disease based on common laboratory values; however, its usefulness for predicting complications after elective arthroplasty has not been studied.

Questions/purposes The purposes of this study were to determine the differences between patients with cirrhosis and control subjects in (1) hospital length of stay, discharge disposition, and readmission within 90 days; (2) early postoperative (90 days) medical complications potentially related to liver disease; (3) surgical complications within 90 days and any time after the procedure; (4) mortality rates after THA and TKA; and in addition, (5) to use the MELD score as a predictor for risk of complications and mortality.

Methods Institutional database query software used coding data identified 115 patients with liver cirrhosis before having THAs or TKAs from 2000 to 2012 and 115 control subjects without cirrhosis matched by age, sex, procedure, and year of surgery. Early postoperative and longer-term medical and surgical complications were compared. Regression analysis was used to determine a MELD score that predicted greater risk of complications.

Results Compared with matched control subjects, patients with cirrhosis had prolonged length of stay and higher rates of discharge to nursing facilities, readmission in 90 days, and urinary tract infections (p < 0.01), renal failure (p = 0.03), blood transfusions (p < 0.01), gastrointestinal hemorrhage (p = 0.04), dislocations (p = 0.01), infections (p = 0.02), and revisions (p = 0.04) within 90 days. One-year (p = 0.01) and longer-term (p = 0.0002) mortality rates were greater in patients with cirrhosis. A MELD score of 10 or greater predicted a three times increased likelihood (odds ratio [OR]) of any complication (95% CI, 1.28-7.00; p = 0.01) and 4.1 times increased likelihood (OR) of death (95% CI, 1.42-11.86; p < 0.01).

Conclusions Patients with cirrhosis undergoing THAs and TKAs should be counseled regarding their increased risk of medical complications, surgical complications, and death. A MELD score of 10 or greater is associated with a high rate of complications, although this finding needs further validation because we were unable to control for all medical confounders.

Level of Evidence Level III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.