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 Adult Knee Reconstruction Test 4: Perioperative Practices/Outcomes
CME 1: January, February, March 2004
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The Journal of Bone and Joint Surgery (American) 86:335-341 (2004)
© 2004 The Journal of Bone and Joint Surgery, Inc.

Total Knee Arthroplasty in Patients with Liver Cirrhosis

Lih-Yuann Shih, MD1, Chun-Ying Cheng, MD1, Chung-Hsun Chang, MD1, Kuo-Yao Hsu, MD1, Robert Wen-Wei Hsu, MD1 and Hsin-Nung Shih, MD1

1 Department of Orthopedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsing Street, Kweishan, 333 Taoyuan, Taiwan, Republic of China. E-mail address for H.-N. Shih: aronc{at}adm.cgmh.org.tw

Investigation performed at the Department of Orthopedic Surgery, Chang-Gung Memorial Hospital and Chang-Gung University, Taiwan, Republic of China.

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: 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.

Methods: 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.

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).

Conclusions: 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.

Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.


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