Total hip arthroplasty in patients with chronic liver disease: A systematic review

Investigation of cell-accelerated corrosion (CAC) on the CoCrMo alloy with segregation banding: Hip implant applications

Metal alloy microstructure plays a crucial role in corrosion associated with total hip replacement (THR). THR is a prominent strategy that uses metal implants such as cobalt-chromium-molybdenum (CoCrMo) alloys due to their advantageous biological and mechanical properties. Despite all benefits, these implants undergo corrosion and wear processes in-vivo in a synergistic manner called tribocorrosion. Also, the implant retrieval findings reported that fretting corrosion occurred in-vivo, evidenced by the damage patterns that appeared on the THR junction interfaces. There is no scientific data on the studies reporting the fretting corrosion patterns of CoCrMo microstructures in the presence of specific biological treatments to date. In the current study, Flat-on-flat fretting corrosion set-up was customized and used to study the tribocorrosion patterns of fretting corrosion to understand the role of alloy microstructure. Alloy microstructural differences were created with the implant stock metal's longitudinal and transverse cutting orientations. As a result, the transverse created the non-banded, homogenous microstructure, whereas the longitudinal cut resulted in the banded, non-homogenous microstructure on the surface of the alloy (in this manuscript, the terms homogenous and banded were used). The induced currents were monitored using a three-electrode system. Three different types of electrolytes were utilized to study the fretting corrosion patterns with both homogeneous and banded microstructures: 1. Control media 2. Spent media (the macrophage cell cultured media) 3. Challenged media (media collected after the macrophage was treated with CoCrMo particles). From the electrochemical results, in the potentiostat conditions, the banded group exhibited a higher induced current in both challenged and spent electrolyte environments than in control due to the synergistic activity of CoCrMo particles and macrophage demonstrating more corrosion loss. Additionally, both Bode and Nyquist plots reported a clear difference between the banded and homogeneous microstructure, especially with challenged electrolytes becoming more corrosion-resistant post-fretting than pre-fretting results. The banded microstructure showed a unique shape of the fretting loop, which may be due to tribochemical reactions. Therefore, from the electrochemical, mechanical, and surface analysis data results, the transverse/homogenous/non-banded alloy microstructure groups show a higher resistance to fretting-corrosion damage.

Patients With Moderate to Severe Liver Cirrhosis Have Significantly Higher Short-Term Complication Rates Following Total Knee Arthroplasty: A Retrospective Cohort Study

BACKGROUND

Liver cirrhosis is associated with increased perioperative morbidity. Our study used the Model for End-Stage Liver Disease (MELD) score to assess the impact of cirrhosis severity on postoperative outcomes following total knee arthroplasty (TKA).

METHODS

A retrospective review identified 59 patients with liver cirrhosis who underwent primary TKA at a large, urban, academic center from January 2013 to August 2022. Cirrhosis was categorized as mild (MELD < 10; n = 47) or moderate-severe (MELD ≥ 10; n = 12). Modified Clavien-Dindo classification was used to grade complications, where grade 2+ denoted significant intervention. Hospital length of stay, nonhome discharge, and mortality were collected. A 1:1 propensity matching was used to control for demographics and selected comorbidities.

RESULTS

Moderate-severe cirrhosis was associated with significantly higher rates of intrahospital overall (58.33 versus 16.67%, P = .036) complications, 30-day overall complications (75 versus 33.33%, P = .042), and 90-day overall complications (75 versus 33.33%, P = .042) when compared to matched mild cirrhosis patients. Compared to matched noncirrhotic controls, mild cirrhosis patients had no significant increase in complication rate or other outcomes (P > .05).

CONCLUSIONS

Patients with moderate-severe liver cirrhosis are at risk of short-term complications following primary TKA. Patients with mild cirrhosis have comparable outcomes to matched noncirrhotic patients. Surgeons can use MELD score prior to scheduling TKA to determine which patients require optimization or higher levels of perioperative care.

Factors that increase the rate of periprosthetic dislocation after reverse shoulder arthroplasty

INTRODUCTION

Reverse shoulder arthroplasty (RSA) is considered one of the greatest technological innovations in shoulder reconstruction surgery, as evidenced by the fact its growth rate of usage is greatest among all shoulder arthroplasties. However, like all arthroplasties, a post-surgical complication often arises. One of these complications, periprosthetic dislocation (PPD), requires revision and poses, therefore, a burden on both patients and healthcare providers. While PPD is understood to be a complication of RSA, it is unclear to what extent certain risk factors and co-morbidities predispose patients to post-RSA PPD. The purpose of this study was to identify and evaluate the impact of specific risk factors and co-morbidities that contribute to the development of PPD following RSA.

METHODS

In this retrospective study, we used the Nationwide Inpatient Sample (NIS) database from 2016-2019 to analyze the prevalence and impact of various risk factors and co-morbidities on the incidence of PPD following RSA. A univariate and subsequent multivariate logistic regression model was made to provide a descriptive association between variables that impact the rates of PPD after RSA.

RESULTS

The NIS database identified 59,925 patients, 1,000 of whom experienced a PPD while the remaining 58,825 were placed in the non-PPD group (controls). The PPD group consisted predominantly of females (53.10%) and Caucasians (86.30%). There was a higher incidence of tobacco-related disorders (P = 0.003), obesity (P < 0.001), morbid obesity (P < 0.001), liver cirrhosis (P < 0.001), and Parkinson's disease (PD) (P < 0.001) in PPD patients compared to controls. Young patients had a 1.89-fold increased odds (OR: 1.89, 95% CI [1.58, 2.26], P < 0.001), patients with tobacco-related disorders had decreased odds (OR: 0.80, 95% CI [0.67, 0.97], P = 0.02), morbidly obese patients had 1.50 times the odds (OR: 1.50, 95% CI [1.14, 1.97]), liver cirrhosis patients had 2.67-fold increased odds (OR: 2.67, 95% CI [1.55, 4.60], P < 0.001), and Parkinson's disease patients had 2.66 times the odds (OR: 2.66, 95% CI [1.78, 3.96], P < 0.001) to develop PPD following RSA compared to patients who did not have the corresponding condition.

CONCLUSIONS

Patients with specific risk factors and co-morbidities are predisposed to developing PPD after RSA. Risk factors that were found to be associated with a higher incidence of PPD are gender (female), race (Caucasian), and age (young patients). Analysis revealed the history of tobacco-related disorder, obesity, morbid obesity, liver cirrhosis, and Parkinson's disease increased the odds of developing PPD following RSA. These findings can inform both healthcare providers and patients to improve RSA surgical outcomes and tailor post-surgery recovery programs to fit the patient's needs.

The role of preoperative aspartate aminotransferase-to-platelet ratio index in predicting complications following total hip arthroplasty

BACKGROUND

The purpose of this study was to investigate the relationship between preoperative aspartate aminotransferase-to-platelet ratio index (APRI) and postoperative complications following total hip arthroplasty (THA).

METHODS

All THA for osteoarthritis patients from 2007 to 2020 within the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database were included in this study. Subjects were subsequently divided into cohorts based on APRI. Four groups, including normal range, some liver damage, significant fibrosis, and cirrhosis groups, were created. Comparisons between groups were made for demographics, past medical history, and rate of major and minor complications. Other outcomes included readmission, reoperation, discharge destination, mortality, periprosthetic fracture, and postoperative hip dislocation. Multivariate logistic regression analysis was performed to determine the role of preoperative APRI in predicting adverse outcomes. Statistical significance was set at p < 0.05.

RESULTS

In total, 104,633 primary THA patients were included in this study. Of these, 103,678 (99.1%) were in the normal APRI group, 444 (0.4%) had some liver damage, 256 (0.2%) had significant fibrosis, and 253 (0.2%) had cirrhosis. When controlling for demographics and relevant past medical history, the abnormal APRI groups had a significantly higher likelihood of major complication, minor complication, intraoperative or postoperative bleeding requiring transfusion, readmission, and non-home discharge (all p < 0.05) compared to normal APRI individuals.

CONCLUSIONS

Abnormal preoperative APRI is linked with an increasing number of adverse outcomes following THA for osteoarthritis for patients across the United States.

LEVEL OF EVIDENCE

Level I.

Safety and outcomes of hip and knee replacement surgery in liver transplant recipients

BACKGROUND

Liver transplant (LT) is becoming increasingly common with improved life expectancy. Joint replacement is usually a safe procedure; however, its safety in LT recipients remains understudied.

AIM

To evaluate the mortality, outcome, and 90-d readmission rate in LT patients undergoing hip and knee replacement surgery.

METHODS

Patients with history of LT who underwent hip and knee replacement surgery between 2016 and 2019 were identified using the National Readmission Database.

RESULTS

A total of 5046119 hip and knee replacement surgeries were identified. 3219 patients had prior LT. Mean age of patients with no history of LT was 67.51 [95% confidence interval (CI): 67.44-67.58], while it was 64.05 (95%CI: 63.55-64.54) in patients with LT. Patients with history of LT were more likely to have prolonged length of hospital stay (17.1% vs 8.4%, P < 0.001). The mortality rate for patients with no history of LT was 0.22%, while it was 0.24% for patients with LT (P = 0.792). Patients with history of LT were more likely to have re-admissions within 90 d of initial hospitalization: 11.4% as compared to 6.2% in patients without history of LT (P < 0.001). The mortality rate between both groups during readmission was not statistically different (1.9% vs 2%, P = 0.871) respectively.

CONCLUSION

Hip and knee replacements in patients with history of LT are not associated with increased mortality; increased re-admissions were more frequent in this cohort of patients. Chronic kidney disease and congestive heart failure appear to predict higher risk of readmission.

Patients With Cirrhosis Have Higher Costs of Care, Longer Length of Stays, and More Perioperative Complications Following Total Knee Arthroplasty: A National Inpatient Sample-Based Study

Background Cirrhosis is a growing disease affecting millions of people in the United States annually. Many cirrhosis patients undergo significant procedures and are met with increased risks such as encephalopathy, impaired immune response, ascites, variceal bleeding, renal disease, and increased malnutrition. Many cirrhosis patients need to undergo major surgical procedures such as total knee arthroplasty (TKA); however, perioperative complications following TKA in cirrhosis patients have not been studied. The purpose of this study was to analyze the demographic characteristics and perioperative complications of cirrhosis patients following TKA. Methods Using the National Inpatient Sample (NIS) database, we looked at retrospective data from the years 2016-2019 to analyze the incidence of perioperative complications, length of stay (LOS), and the cost of care (COC) among patients undergoing TKA who were categorized as cirrhosis patients, compared with those who are not. A propensity match was conducted to consider associated comorbidities that influence perioperative complications. Results Of the 558,256 patients analyzed who underwent TKA, 1670 (0.3%) were diagnosed with cirrhosis. After matching, cirrhosis patients had a longer LOS (4.22 vs. 3.68 days, p=0.016) and COC ($90,624 vs. 80676.87, p<0.001) than patients in the control group. Moreover, cirrhosis patients had a higher likelihood of developing acute renal failure (odds ratio (OR): 3.05, 95% CI: 2.07-4.50, p<0.001), blood loss anemia (OR: 1.60, 95% CI: 1.34-1.92, p<0.001), periprosthetic fracture (OR: 3.27, 95% CI: 1.31-8.18, p=0.007), periprosthetic infection (OR: 3.14, 95% CI: 1.99-4.95, p<0.001), and blood transfusions (OR: 1.62, 95% CI: 1.12-2.35, p=0.009) than patients in the control group. Conclusion The cirrhosis group had a significantly higher COC, longer LOS, and higher rates of perioperative complications than non-cirrhosis patients. This data will help providers make informed decisions about patient care and resource allocation for cirrhosis patients undergoing TKA.

Preoperative Risk Stratification in Arthroscopic Rotator Cuff Repair: Aspartate Aminotransferase-to-Platelet Ratio Index as an Estimate of Liver Dysfunction

BACKGROUND

Aspartate Aminotransferase-to-Platelet Ratio Index (APRI) is a cost-effective and noninvasive measure of liver function, an alternative to the gold standard liver biopsy which is resource-intensive and invasive. This study investigates the association between various degrees of liver dysfunction based on APRI and 30-day postoperative complications following arthroscopic rotator cuff repair (aRCR).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent aRCR between 2015 and 2021. The study population was divided into four groups based on preoperative APRI: normal/reference (APRI ≤ 0.5), mild fibrosis (0.5 < APRI ≤ 0.7), significant fibrosis (0.7 < APRI ≤ 1), and cirrhosis (APRI > 1). Multivariate logistic regression analysis was conducted to investigate the connection between preoperative APRI and postoperative complications.

RESULTS

Compared to normal liver function, mild fibrosis was significantly associated with male gender, lower BMI, American Society of Anesthesiologists (ASA) classification ≥ 3, and comorbid diabetes, hypertension, chronic obstructive pulmonary disease, and bleeding disorders. Significant fibrosis was significantly associated with male gender, greater BMI, ASA classification ≥ 3, and comorbid diabetes, hypertension, and bleeding disorders. Cirrhosis was significantly associated with younger age, ASA classification ≥ 3, smokers, and comorbid diabetes and bleeding disorders. Compared to normal liver function, fibrosis was not associated with complications, significant fibrosis was associated with myocardial infarction, and cirrhosis was associated with major complications, sepsis, non-home discharge, and mortality. However, mild fibrosis, significant fibrosis, and cirrhosis were independently associated with any adverse 30-day postoperative complications following aRCR.

CONCLUSION

Among those with predicted liver damage based on preoperative APRI, 30-day postoperative complications following aRCR were not found to be independently associated with preoperative mild fibrosis, significant fibrosis, or cirrhosis. Our results suggest that APRI predictive of liver dysfunction may be a weaker deterrent to undergoing aRCR compared to other orthopedic surgeries.

Guidance document: risk assessment of patients with cirrhosis prior to elective non-hepatic surgery

As a result of the increasing incidence of cirrhosis in the UK, more patients with chronic liver disease are being considered for elective non-hepatic surgery. A historical reluctance to offer surgery to such patients stems from general perceptions of poor postoperative outcomes. While this is true for those with decompensated cirrhosis, selected patients with compensated early-stage cirrhosis can have good outcomes after careful risk assessment. Well-recognised risks include those of general anaesthesia, bleeding, infections, impaired wound healing, acute kidney injury and cardiovascular compromise. Intra-abdominal or cardiothoracic surgery are particularly high-risk interventions. Clinical assessment supplemented by blood tests, imaging, liver stiffness measurement, endoscopy and assessment of portal pressure (derived from the hepatic venous pressure gradient) can facilitate risk stratification. Traditional prognostic scoring systems including the Child-Turcotte-Pugh and Model for End-stage Liver Disease are helpful but may overestimate surgical risk. Specific prognostic scores like Mayo Risk Score, VOCAL-Penn and ADOPT-LC can add precision to risk assessment. Measures to mitigate risk include careful management of varices, nutritional optimisation and where possible addressing any ongoing aetiological drivers such as alcohol consumption. The role of portal decompression such as transjugular intrahepatic portosystemic shunting can be considered in selected high-risk patients, but further prospective study of this approach is required. It is of paramount importance that patients are discussed in a multidisciplinary forum, and that patients are carefully counselled about potential risks and benefits.

Cirrhosis and non-hepatic surgery in 2023 - a precision medicine approach

INTRODUCTION

Patients with liver disease and portal hypertension frequently require surgery carrying high morbidity and mortality. Accurately estimating surgical risk remains challenging despite improved medical and surgical management.

AREAS COVERED

This review aims to outline a comprehensive approach to preoperative assessment, appraise methods used to predict surgical risk, and provide an up-to-date overview of outcomes for patients with cirrhosis undergoing non-hepatic surgery.

EXPERT OPINION

Robust preoperative, individually tailored, and precise risk assessment can reduce peri- and postoperative complications in patients with cirrhosis. Established prognostic scores aid stratification, providing an estimation of postoperative mortality, albeit with limitations. VOCAL-Penn Risk Score may provide greater precision than established liver severity scores. Amelioration of portal hypertension in advance of surgery may be considered, with prospective data demonstrating hepatic venous pressure gradient as a promising surrogate marker of postoperative outcomes. Morbidity and mortality vary between types of surgery with further studies required in patients with more advanced liver disease. Patient-specific considerations and practicing precision medicine may allow for improved postoperative outcomes.

Comparison of Prognostic Value of 10 Biochemical Indices at Admission for Prediction Postoperative Myocardial Injury and Hospital Mortality in Patients with Osteoporotic Hip Fracture

Aim: To evaluate the prognostic impact at admission of 10 biochemical indices for prediction postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In 1273 consecutive patients with HF (mean age 82.9 ± 8.7 years, 73.5% women), clinical and laboratory parameters were collected prospectively, and outcomes were recorded. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were preformed, the number needed to predict (NNP) outcome was calculated. Results: Age ≥ 80 years and IHD were the most prominent clinical factors associated with both PMI (with cardiac troponin I rise) and in-hospital death. PMI occurred in 555 (43.6%) patients and contributed to 80.3% (49/61) of all deaths (mortality rate 8.8% vs. 1.9% in non-PMI patients). The most accurate biochemical predictive markers were parathyroid hormone > 6.8 pmol/L, urea > 7.5 mmol/L, 25(OH)vitamin D < 25 nmol/L, albumin < 33 g/L, and ratios gamma-glutamyl transferase (GGT) to alanine aminotransferase > 2.5, urea/albumin ≥ 2.0 and GGT/albumin ≥ 7.0; the AUC for developing PMI ranged between 0.782 and 0.742 (NNP: 1.84−2.13), the AUC for fatal outcome ranged from 0.803 to 0.722, (NNP: 3.77−9.52). Conclusions: In HF patients, easily accessible biochemical indices at admission substantially improve prediction of hospital outcomes, especially in the aged >80 years with IHD.

Complications and predictors of morbidity for hip fracture surgery in patients with chronic liver disease

BACKGROUND

Despite the fact that patients with chronic liver disease (CLD) are at increased risk of complications after a fracture of the hip, there remains little information about the risk factors for acute postoperative complications and their overall outcome.The aim of this study was to describe inpatient postoperative complications and identify predictors of postoperative morbidity.

METHODS

Patients with CLD who had been treated for a fracture of the hip between April 2005 and August 2019 were identified from a retrospective search of an intramural trauma registry based in the Northeastern United States. Medical records were reviewed for baseline demographics, preoperative laboratory investigations, and outcomes.

RESULTS

The trauma registry contained 110 patients with CLD who had undergone surgery for a fracture of the hip. Of these, patients with a platelet-count of ⩽100,000/µL were 3.81 (95% CI, 1.59-9.12) times more likely to receive a transfusion than those with a platelet-count of >100,000/µL. Those with a Model for End-stage Liver Disease (MELD) score of >9 were 5.54 (2.33-13.16) times more likely to receive a transfusion and 3.97 (1.06-14.81) times more likely to develop postoperative delirium than those with a MELD score of ⩽9.Of patients without chronic kidney disease, those with a creatinine of ⩾1.2 mg/dL were 6.80 (1.79-25.87) times more likely to develop acute renal failure (ARF) than those with a creatinine of <1.2 mg/dL. In a multivariable model, as MELD score was increased, the odds of developing a composite postoperative complication, which included transfusion, ARF, delirium, or deep wound infection, were 1.29 (1.01-1.66). Other tools used to assess surgical risks, Charlson Comorbidity Index, Elixhauser, and American Society of Anesthesiologist scores, were not predictive.

CONCLUSIONS

Patients with CLD who undergo surgery for a hip fracture have a high rate of postoperative complications which can be predicted by the preoperative laboratory investigations identified in this study and MELD scores, but not by other common comorbidity indices.

Chronic liver disease and cirrhosis increase morbidity in geriatric patients treated surgically for hip fractures: analysis of the US Nationwide Inpatient Sample

Background

This study aimed to evaluate the impact of chronic liver disease and cirrhosis on inpatient outcomes of geriatric hip fracture surgery.

Materials and methods

Using population-based retrospective study design, this study extracted data from the US Nationwide Inpatient Sample (NIS) database 2005–2014, identifying patients aged ≥ 65 years undergoing hip fracture repair. Main outcomes were in-hospital mortality, any/specific complications, non-routine discharge, extended length of stay (LOS) and hospital costs. Associations between cirrhosis, non-cirrhotic chronic liver disease and outcomes were determined using regression analysis.

Results

Data of 347,363 hip fracture patients included 344,035 without liver disease, 1257 with non-cirrhotic chronic liver disease and 2,071 with cirrhosis. After adjustments, non-cirrhotic chronic liver disease was significantly associated with non-routine discharge (OR: 1.247, 95% CI: 1.038–1.498), acute kidney injury (OR: 1.266, 95% CI: 1.039–1.541), extended LOS (OR: 1.285, 95% CI: 1.122–1.473) and hospital costs (beta: 9173.42, 95% CI: 6925.9–11,420.95) compared to no liver disease; while cirrhosis was significantly associated with higher risk of in-hospital mortality (OR: 2.325, 95% CI: 1.849–2.922), any complication (OR: 1.295, 95% CI: 1.143–1.467), acute kidney injury (OR: 1.242, 95% CI: 1.177–1.433), non-routine discharge (OR: 1.650, 95% CI: 1.412–1.928), extended LOS (OR: 1.405, 95% CI: 1.263–1.562) and hospital costs (beta: 6680.24, 95% CI: 4921.53–8438.95) compared to no liver disease.

Conclusion

In geriatric hip fracture patients undergoing surgical repair, non-cirrhotic chronic liver disease and cirrhosis independently predict non-routine discharge, acute kidney injury, prolonged LOS and greater hospital costs, and cirrhosis is also significantly associated with greater risk of any complication and in-hospital mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02832-y.

Revision Risk in a Cohort of US Patients Younger Than 55 Undergoing Primary Elective Total Hip Arthroplasty

BACKGROUND

As indications for elective total hip arthroplasty (THA) expand to younger patients, we sought to (1) compare revision risk following primary elective THA in patients <55 years at the time of their THA to patients aged ≥65 years and (2) identify specific risk factors for revision in patients <55 years.

METHODS

A Kaiser Permanente's total joint replacement registry was used to conduct a cohort study including primary elective THA patients aged ≥18 (2001-2018). In total, 11,671 patients <55 years and 53,106 patients ≥65 years were included. Multiple Cox regression was used to evaluate cause-specific revision risk, including septic revision, aseptic loosening, instability, and periprosthetic fracture. Stepwise Cox regression was used to identify patient and surgical factors associated with cause-specific revision in patients <55 years.

RESULTS

Patients <55 years had a higher risk of septic revision (hazard ratio [HR] = 1.30, 95% confidence interval [CI] = 1.02-1.66), aseptic loosening (HR = 2.60, 95% CI = 1.99-3.40), and instability (HR = 1.35, 95% CI = 1.09-1.68), but a lower risk of revision for periprosthetic fracture (HR = 0.36, 95% CI = 0.22-0.59) compared to patients aged ≥65 years. In the <55 age group, risk factors for septic revision included higher body mass index, drug abuse, and liver disease. Hypertension, anterior approach, and ceramic-on-ceramic were associated with aseptic loosening. White race, American Society of Anesthesiologists classification ≥3, smoker, paralysis, posterior approach, ceramic-on-ceramic, and smaller head diameter were associated with instability.

CONCLUSION

Identified risk factors varied depending on the cause for revision. Although septic revisions were related to patient characteristics, more modifiable factors, such as implant or surgical approach, were associated with revision due to aseptic loosening and instability.

LEVEL OF EVIDENCE

III.

How to Prevent Aseptic Loosening in Cementless Arthroplasty: A Review

Aseptic loosening is the main late postoperative complication of cementless total hip arthroplasties (THAs), leading to pain and functional impairment. This article aims to update the orthopedic surgeon on the various methods by which the aseptic loosening rate can be reduced. We performed a systematic review by searching the PubMed database for hip aseptic loosening. We included meta-analysis, randomized controlled trials, reviews, and systematic reviews in the last 10 years, which provided information on techniques that can prevent aseptic loosening in total hip arthroplasty. From a total of 3205 articles identified, 69 articles (2%) met the inclusion criteria, leading to a total of 36 recommendations. A lot of research has been conducted in terms of septic loosening in the last decade. Currently, we have various techniques by which we can reduce the rate of aseptic loosening. Nevertheless, further randomized clinical trials are needed to expand the recommendations for aseptic loosening prevention.

Common musculoskeletal disorders in chronic liver disease patients

Chronic liver disease (CLD) is the commonest ailment affecting the hepatobiliary system. Six significant pathologies related to CLD include hepatic osteodystrophy (HO), increased infection susceptibility, sarcopenia, osteonecrosis of the femoral head (OFH), increased risk of periprosthetic complications and fracture. Hepatic osteodystrophy, which comprises osteopenia, osteoporosis, and osteomalacia, refers to alterations in bone mineral metabolism found in patients with CLD. The HO prevalence ranges from 13 to 95%. Low complement levels, poor opsonization capacity, portosystemic shunting, decreased albumin levels, and impaired reticuloendothelial system make the cirrhotic patients more susceptible to developing infectious diseases. Septic arthritis, osteomyelitis, prosthetic joint infection, and cellulitis were common types of CLD-associated infectious conditions. The incidence of septic arthritis is 1.5 to 2-fold higher in patients with cirrhosis. Sarcopenia, also known as muscle wasting, is one of the frequently overlooked manifestations of CLD. Sarcopenia has been shown to be independent predictor of longer mechanical ventilation, hospital stay, and 12-month mortality of post-transplantation. Alcohol and steroid abuse commonly associated with CLD are the two most important contributory factors for non-traumatic osteonecrosis. However, many studies have identified cirrhosis alone to be an independent cause of atraumatic osteonecrosis. The risk of developing OFH in cirrhosis patients increases by 2.4 folds and the need for total hip arthroplasty increases by 10 folds. Liver disease has been associated with worse outcomes and higher costs after arthroplasty. Cirrhosis is a risk factor for arthroplasty complications and is associated with a prolonged hospital stay, higher costs, readmission rates, and increased mortality after arthroplasty. Greater physician awareness of risk factors associated with musculoskeletal complications of CLD patients would yield earlier interventions, lower healthcare costs, and better overall clinical outcomes for this group of patients.

A Complication Profile of Total Hip and Knee Arthroplasty in Liver Transplantation Patients: A Meta-Analysis

BACKGROUND

There is an increasing demand for total joint arthroplasty in liver transplantation patients. However, significant heterogeneity in existing studies creates difficulty to draw conclusions on the risk profile of arthroplasty in this population.

METHODS

A systematic review of the literature dated from 1980 to 2020 describing the complication rates of liver transplantation patients receiving either total hip or knee arthroplasty was conducted. Multiple outcomes were extracted and a meta-analysis was performed. Four cohorts were created for analysis purposes: liver transplant patients undergoing THA and TKA (1), THA only (2), TKA only (3), and controls (4).

RESULTS

A total of 13 studies were included in this meta-analysis, accounting for 3024 liver transplantation patients. The rate of infection (odds ratio [OR] = 2.14, OR = 1.61, OR = 2.52), myocardial infarction (OR = 1.65, OR = 1.75, OR = 1.57), respiratory failure (OR = 2.19, OR = 2.50, OR = 1.96), acute kidney injury (OR = 5.71, OR = 5.40, OR = 4.35), sepsis (OR = 3.72, OR = 3.30, OR = 4.02), and blood transfusions (OR = 2.09, OR = 3.65, OR = 1.74) were all significantly higher in the 3 cohorts compared to the controls. Revision/reoperation rates were significantly higher in cohorts 1 and 3 (OR = 1.52 and OR = 1.62, respectively). Patient-reported outcomes saw improvements in Harris Hip Score, objective Knee Society Score, and functional Knee Society Score postoperatively (average improvement = 32.4, 37.2, and 15.3, respectively).

CONCLUSION

Liver transplantation patients functionally benefit from total hip and knee arthroplasty, but at the cost of increased risk of infection, revision/reoperation, and medically related complications compared to controls. Mortality may also be a short-term risk.

Risk factors for mortality following one-stage septic hip arthroplasty - a case-control study

PURPOSE

Despite good clinical outcomes and a high success rate, there is a comparatively high mortality after one stage septic exchange of total hip arthroplasty. The aim of this study was to identify risk factors for mortality in the hospitalization period after one-stage septic exchange of THA.

METHODS

We retrospectively analyzed in our database all patients who had a one-stage septic exchange for periprosthetic infection of THA and died during hospitalization (n = 33). The control group was matched semi-randomly by surgical procedure (n = 121) who did not die during hospitalization. The two groups were analyzed for risk factors such as age, Charlson Comorbidity Index (CCI), and high-/low-virulence bacteria.

RESULTS

In the deceased group, 16 patients were female and 17 were male with a mean age at surgery of 73.2 years. In the control group, there were 55 females and 66 males with an average age at surgery of 68.2 years. Comparing the two groups, the deceased group had a significantly higher proportion of liver disease as well as higher rate of pulmonary embolism, apoplexy, and/or myocardial infarction, an increased CCI with an average of 6.5 and advanced age. Further demographic and surgery-related parameters especially high- or low-virulent germs were not identified as risk factors for mortality during the hospitalization period. The binominal logistic regression analysis showed that the probability of an inpatient death following one-stage septic exchange of THA increases by a factor of 3.079, with each additional point of the CCI.

CONCLUSION

In conclusion, advanced age and high CCI are the main risk factors for mortality after single-stage septic change of THA. However, high-virulence bacteria have no influence on the mortality during the hospitalization period after one-stage septic exchange of THA.

Compensated Cirrhosis Is Associated With Increased Risk of Complications Following Total Hip Arthroplasty in a Large Medicare Database

BACKGROUND

The aim of this study is to evaluate medical and surgical complications of liver cirrhosis patients following total hip arthroplasty (THA), with attention to different etiologies of cirrhosis and their financial burden following THA.

METHODS

In total, 18,321 cirrhotics and 722,757 non-cirrhotics who underwent primary elective THA between 2006 and 2013 were identified from a retrospective database review. This cohort was further subdivided into 2 major etiologies of cirrhosis (viral and alcoholic cirrhosis) and other cirrhotic etiology. Cirrhotics were compared to non-cirrhotics for hospital length of stay, 90-day mean total charges and reimbursement, hospital readmission, and major medical and arthroplasty-specific complications.

RESULTS

Cirrhosis was associated with increased rates of major medical complications (4.3% vs 2.4%; odds ratio [OR] 1.20, P < .001), minor medical complications, transfusion (3.4% vs 2.1%; OR 1.16, P = .001), encephalopathy, disseminated intravascular coagulation, and readmission (13.5% vs 8.6%; OR 1.18, P < .001) within 90 days. Cirrhosis was associated with increased rates of revision, periprosthetic joint infection, hardware failure, and dislocation within 1 year postoperatively (3.1% vs 1.6%; OR 1.37, P < .001). Cirrhosis independently increased hospital length of stay by 0.14 days (P < .001), and it independently increased 90-day charges and reimbursements by $13,791 (P < .001) and $1707 (P < .001), respectively. Viral and alcoholic cirrhotics had higher rates of 90-day and 1-year complications compared to controls-other causes only had higher rates of 90-day medical complications, encephalopathy, readmission, and 1-year revision, hardware failure, and dislocation compared to controls.

CONCLUSION

Cirrhosis, especially viral and alcoholic etiologies, is associated with higher risk of early postoperative complications and healthcare utilization following elective THA.

The Impact of Hepatitis C and Liver Disease on Risk of Complications After Total Hip and Knee Arthroplasty: Analysis of Administrative Data From Louisiana and Texas

Background

Millions of Americans have hepatitis C and other liver diseases, many of whom have end-stage osteoarthritis requiring total joint arthroplasty (TJA). This study aimed to determine the extent to which hepatitis C and other liver diseases are independent risk factors for complications, including readmission and reoperation, in patients undergoing TJA.

Methods

Retrospective study of a REACHnet data set containing demographics, International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes, and clinical and laboratory data for patients who underwent primary total knee or hip replacement from 2013 to 2017 at 3 hospital systems in Louisiana and Texas. Multivariable logistic regression analyses examined predictors of complications. Any complication was defined as a 90-day medical complication or readmission or reoperation within 1 year.

Results

Among 13,673 patients who met inclusion criteria, 14.9% (2044/13,673) had any complication, 11.7% (1600/13,673) were readmitted within 90 days, and 3.6% (497/13,673) had a reoperation within 1 year. Liver disease increased the odds for any complication (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.08-1.18), 90-day medical complication (OR, 1.13; 95% CI, 1.04-1.22), and 90-day readmission (OR, 1.11; 95% CI, 1.06-1.17). Hepatitis C was not, by itself, associated with an increase in any type of complication but was usually associated with liver disease. Comorbidity severity was the strongest predictor of all types of complications after TJA.

Conclusion

Patients in Louisiana and Texas with liver disease were at increased risk for complications after TJA, corroborating findings of previous studies. Hepatitis C was not an independent predictor of complications because of its high association with liver disease.

Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.