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.