Shih Lih-Yuann, Cheng Chun-Ying, Chang Chung-Hsun, Hsu Kuo-Yao, Hsu Robert Wen-Wei, Shih Hsin-Nung
Department of Orthopedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsing Street, Kweishan, 333 Taoyuan, Taiwan, Republic of China.
J Bone Joint Surg Am. 2004 Feb;86(2):335-41. doi: 10.2106/00004623-200402000-00017.
Patients with liver cirrhosis have an increased risk of surgical morbidity and mortality. We are aware of no study that has investigated the risks and outcomes of elective orthopaedic procedures in these patients. The purposes of the present study were to review the results of total knee arthroplasty in patients with cirrhosis and to identify risk factors leading to poor results.
Fifty-one patients with cirrhosis who had undergone sixty total knee arthroplasties for osteoarthritis were studied. The medical records and laboratory data were collected retrospectively. All data were compared with those for matched patients without cirrhosis. Forty-two patients (fifty-one knees) with complete follow-up were evaluated with regard to complications, mortality, and factors leading to poor results.
Total knee arthroplasty was associated with significantly more blood loss, a longer hospital stay, more complications, and a higher mortality rate in patients with cirrhosis as compared with control patients (p </= 0.006 for all). Twenty-six complications occurred in twenty patients (twenty-two knees). Logistic regression analysis showed that a history of hepatic decompensation or variceal bleeding was an independent predictor of complications. Infection was the most common complication (prevalence, 21%). Age, platelet count, and hepatitis-B-related cirrhosis were independent predictors of infection. There were no perioperative deaths. Fifteen patients died at a mean of forty-three months after total knee arthroplasty; two deaths were related to the procedure. The presence of a hepatoma was found to be a significant predictor of mortality (p < 0.001).
The rate of complications after total knee arthroplasty was significantly higher in patients with cirrhosis than in control patients (p < 0.001). We believe that total knee arthroplasty should not be performed in patients with a history of hepatic decompensation or variceal bleeding. The risk of infection was high in older patients, patients with a low platelet count, and patients in whom the cirrhosis was related to the hepatitis-B virus. Aggressive prophylaxis against infection should be performed. Patients with Child class-A cirrhosis without these risk factors may do well following a total knee arthroplasty. The benefit of total knee arthroplasty should be cautiously weighed against its potential risks in patients with cirrhosis.
肝硬化患者手术并发症及死亡率风险增加。我们所知，尚无研究调查过此类患者择期骨科手术的风险及结果。本研究的目的是回顾肝硬化患者全膝关节置换术的结果，并确定导致不良结果的风险因素。
对51例因骨关节炎接受60次全膝关节置换术的肝硬化患者进行研究。回顾性收集病历及实验室数据。将所有数据与匹配的非肝硬化患者的数据进行比较。对42例（51膝）有完整随访资料的患者，就并发症、死亡率及导致不良结果的因素进行评估。
与对照组患者相比，肝硬化患者全膝关节置换术的失血量显著更多、住院时间更长、并发症更多、死亡率更高（所有比较p≤0.006）。20例患者（22膝）发生了26例并发症。Logistic回归分析显示，肝失代偿或静脉曲张出血史是并发症的独立预测因素。感染是最常见的并发症（发生率为21%）。年龄、血小板计数及乙型肝炎相关肝硬化是感染的独立预测因素。围手术期无死亡病例。15例患者在全膝关节置换术后平均43个月死亡；2例死亡与手术相关。发现肝癌的存在是死亡率的显著预测因素（p<0.001）。
肝硬化患者全膝关节置换术后的并发症发生率显著高于对照组患者（p<0.001）。我们认为，有肝失代偿或静脉曲张出血史的患者不应进行全膝关节置换术。老年患者、血小板计数低的患者以及肝硬化与乙型肝炎病毒相关的患者感染风险高，应积极预防感染。无这些风险因素的Child A级肝硬化患者全膝关节置换术后可能效果良好。对于肝硬化患者，应谨慎权衡全膝关节置换术的益处与其潜在风险。
