Tiberi John V, Hansen Viktor, El-Abbadi Naglaa, Bedair Hany
Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA,
Clin Orthop Relat Res. 2014 Sep;472(9):2774-8. doi: 10.1007/s11999-014-3681-z. Epub 2014 Jul 4.
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.
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.
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).
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 III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.
对于接受全髋关节置换术（THA）和全膝关节置换术（TKA）的肝硬化患者，风险分层至关重要，因为他们更有可能出现严重的内科和外科并发症。与在评估腹水和肝性脑病方面经验有限的骨科医生使用受限的Child-Pugh评分系统不同，终末期肝病模型（MELD）是一种基于常见实验室值的、易于计算且经过验证的肝病严重程度评分系统；然而，其对择期关节置换术后并发症的预测作用尚未得到研究。
问题/目的：本研究的目的是确定肝硬化患者与对照受试者在以下方面的差异：（1）住院时间、出院去向及90天内再入院情况；（2）术后早期（90天）可能与肝病相关的内科并发症；（3）90天内及术后任何时间的外科并发症；（4）THA和TKA后的死亡率；此外，（5）使用MELD评分作为并发症和死亡风险的预测指标。
机构数据库查询软件利用编码数据识别出2000年至2012年期间在接受THA或TKA之前患有肝硬化的115例患者以及115例无肝硬化的对照受试者，后者在年龄、性别、手术方式和手术年份方面进行了匹配。比较了术后早期和长期的内科及外科并发症。采用回归分析确定预测并发症风险更高的MELD评分。
与匹配的对照受试者相比，肝硬化患者住院时间延长，转至护理机构的比例更高，90天内再入院率、尿路感染率（p < 0.01）、肾衰竭率（p = 0.03）、输血率（p < 0.01）、胃肠道出血率（p = 0.04）、90天内脱位率（p = 0.01）、感染率（p = 0.02）和翻修率（p = 0.04）更高。肝硬化患者的1年死亡率（p = 0.01）和长期死亡率（p = 0.0002）更高。MELD评分≥10预测任何并发症的可能性增加3倍（优势比[OR]）（95%可信区间[CI]，1.28 - 7.00；p = 0.01），死亡可能性增加4.1倍（OR）（95% CI，1.42 - 11.86；p < 0.01）。
对于接受THA和TKA的肝硬化患者，应告知他们内科并发症、外科并发症和死亡风险增加的情况。MELD评分≥10与高并发症发生率相关，尽管这一发现需要进一步验证，因为我们无法控制所有内科混杂因素。
III级，预后研究。有关证据水平的完整描述，请参阅作者须知。
