Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
Clin Orthop Relat Res. 2023 Oct 1;481(10):2016-2025. doi: 10.1097/CORR.0000000000002631. Epub 2023 Mar 24.
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?
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.
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).
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 III, therapeutic study.
接受初次择期全关节置换术（TJA）的丙型肝炎病毒（HCV）患者术后发生并发症的风险增加。患有慢性肝病和肝硬化（特别是 Child-Pugh B 级和 C 级）并接受普通外科手术的患者，2 年死亡率风险很高，接近 60%至 80%。然而，Child-Pugh 和终末期肝病模型（Model for End-Stage Liver Disease，MELD）分类的肝脏状况在预测 HCV 患者接受择期关节置换术后的生存率方面的作用尚未阐明。
问题/目的：哪些因素与 HCV 患者接受关节置换术后的早期（<2 年）死亡率独立相关？
我们在三家三级学术医疗中心进行了一项回顾性研究，确定了 2005 年 1 月至 2019 年 12 月期间接受初次择期 TJA 的 HCV 患者。排除接受翻修 TJA 和同时初次 TJA 的患者。共有 226 名患者符合研究纳入标准。由于随访时间不足 2 年或失访（57 名患者，占 25%）或数据集不完整，有 25%的患者被排除在外。在应用纳入和排除标准后，最终队列由最初符合分析条件的患者人群的 75%（226 名患者中的 169 名）组成。平均随访时间为 53 ± 29 个月。我们比较了死亡率方面的混杂变量，包括早期死亡（16 名患者）和存活患者（153 名患者）之间的合并症、HCV 和肝脏特征、HCV 治疗以及术后医疗和手术并发症。早期术后死亡患者更可能存在相关的高级 Child-Pugh 分类和合并症，包括外周血管疾病、终末期肾病、心力衰竭和慢性阻塞性肺疾病。然而，两组的 90 天和 1 年医疗并发症风险相似，包括心肌梗死、中风、肺栓塞以及因假体周围关节感染和机械故障而再次手术。进行了多变量回归分析，以确定与 HCV 患者接受择期 TJA 后早期（<2 年）死亡相关的独立因素，纳入了单变量分析中 p<0.05 的所有显著变量。
在考虑了单变量分析中显著的变量（如外周血管疾病、终末期肾病、心力衰竭、慢性阻塞性肺疾病和纤维化分期）后，Child-Pugh B 或 C 级被发现是 HCV 患者接受择期 TJA 后早期（<2 年）死亡风险增加的唯一独立因素（调整后的优势比 29 [95%置信区间 5 至 174]；p<0.001）。Child-Pugh B 或 C 级患者的早期死亡率风险为 64%（11 名患者中的 7 名），而 Child-Pugh A 级患者的早期死亡率风险为 6%（158 名患者中的 9 名）（p<0.001）。
接受择期 TJA 的 HCV 患者中，Child-Pugh B 或 C 级患者的死亡风险显著增加，无论肝功能、肝硬化、年龄、MELD 分级、HCV 治疗和病毒载量状态如何。这类似于接受腹部和心脏手术的慢性肝病患者的早期死亡率风险。外科医生应尽可能避免 Child-Pugh B 或 C 级患者进行这些主要的择期手术。对于那些感到自己的关节炎症状和疼痛无法忍受的患者，外科医生需要明确死亡风险显著增加。
III 级，治疗性研究。
