Joint Replacement

Save a Life — Risk of Death After Arthroplasty in Patients With Liver Disease

Most patients with Class B or C liver disease will die within 2 years of joint replacement; identifying them is crucial.

What’s the Claim?

In a recent study of patients with a history of hepatitis C, the only factor associated with an increased risk of death after elective total joint arthroplasty was more-advanced signs of liver failure (Class B or C on the Child-Pugh classification). And it was a doozy — seven of 11 such patients died within two years of surgery, compared with only 6% of patients with hepatitis C who had milder (Child-Pugh class A) liver disease. That’s an odds ratio of 29, with the most-conservative bound on the 95% CI showing a 5x increase in the odds of death.

How’s It Stack Up?

In order to use this study’s findings, you need to be able to calculate a patient’s Child-Pugh classification. Fortunately, this is easily done in about 5 seconds with a freely available online calculator using the following chart data:

Total bilirubin
Albumin
INR
Ascites (absent, slight, or moderate)
Presence or absence of encephalopathy

While other studies have evaluated the risk of infection and other complications after arthroplasty among patients with hepatitis C (both are elevated, no surprise), and there are risk calculators available for patients with liver failure who are contemplating abdominal surgery, this study is by far the most definitive one on the endpoint of death after joint replacement, or even after major orthopaedic surgery.

What’s Our Take?

Most of us don’t see patients with hepatitis C every day, but we all see them from time to time. The discoveries in this study are practical for you and practice-changing (indeed, life-changing) for them. It’s not good news — no one said staring into the existential abyss would be easy — but the findings here help us to do some reality checking with patients who trust us to help them make good choices. Some of them may say that the pain is bad enough to risk both limb and life to try to alleviate it with joint replacement. Others, not. For the latter group, we need to support them with compassionate, thoughtful approaches to adapting to their limitations and treating their pain. This may be one of the rare indications for using narcotic analgesics in patients with arthritis. Either way, it’s our job to give them that choice based on the best-available evidence. This is that evidence.