Increase in perioperative complications following primary total hip and knee arthroplasty in patients with hepatitis C without cirrhosis

Racial Disparities in Treatment and Outcomes of Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty

BACKGROUND

African Americans have the highest prevalence of chronic Hepatitis C virus (HCV) infection. Racial disparities in outcome are observed after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study sought to identify if disparities in treatments and outcomes exist between Black and White patients who have HCV prior to elective THA and TKA.

METHODS

Patient demographics, comorbidities, HCV characteristics, perioperative variables, in-hospital outcomes, and postoperative complications at 1-year follow-up were collected and compared between the 2 races. Patients who have preoperative positive viral load (PVL) and undetectable viral load were identified. Chi-square and Fisher's exact tests were used to compare categorical variables, while 2-tailed Student's Kruskal-Wallis t-tests were used for continuous variables. A P value of less than .05 was statistically significant.

RESULTS

The liver function parameters, including aspartate aminotransferase and model for end-stage liver disease scores, were all higher preoperatively in Black patients undergoing THA (P = .01; P < .001) and TKA (P = .03; P = .003), respectively. Black patients were more likely to undergo THA (65.8% versus 35.6%; P = .002) and TKA (72.1% versus 37.3%; 0.009) without receiving prior treatment for HCV. Consequently, Black patients had higher rates of preoperative PVL compared to White patients in both THA (66% versus 38%, P = .006) and TKA (72% versus 37%, P < .001) groups. Black patients had a longer length of stay for both THA (3.7 versus 3.3; P = .008) and TKA (4.1 versus 3.0; P = .02).

CONCLUSIONS

The HCV treatment prior to THA and TKA with undetectable viral load has been shown to be a key factor in mitigating postoperative complications, including joint infection. We noted that Black patients were more likely to undergo joint arthroplasty who did not receive treatment and with a PVL. While PVL rates decreased over time for both races, a significant gap persists for Black patients.

Hepatitis C Virus Infection and Hospital-Related Outcomes: A Systematic Review

Background

People living with hepatitis C infection (HCV) have a significant impact on the global healthcare system, with high rates of inpatient service use. Direct-acting antivirals (DAAs) have the potential to alleviate this burden; however, the evidence on the impact of HCV infection and hospital outcomes is undetermined. This systematic review aims to assess this research gap, including how DAAs may modify the relationship between HCV infection and hospital-related outcomes.

Methods

We searched five databases up to August 2022 to identify relevant studies evaluating the impact of HCV infection on hospital-related outcomes. We created an electronic database of potentially eligible articles, removed duplicates, and then independently screened titles, abstracts, and full-text articles.

Results

A total of 57 studies were included. Analysis of the included studies found an association between HCV infection and increased number of hospitalizations, length of stay, and readmissions. There was less consistent evidence of a relationship between HCV and in-hospital mortality. Only four studies examined the impact of DAAs, which showed that DAAs were associated with a reduction in hospitalizations and mortality. In the 14 studies available among people living with HIV, HCV coinfection similarly increased hospitalization, but there was less evidence for the other hospital-related outcomes.

Conclusions

There is good to high-quality evidence that HCV negatively impacts hospital-related outcomes, primarily through increased hospitalizations, length of stay, and readmissions. Given the paucity of studies on the effect of DAAs on hospital outcomes, future research is needed to understand their impact on hospital-related outcomes.

Hepatitis C Is Associated With Higher Short-Term Complication Rates After Initial Aseptic and Septic Revision Total Hip Arthroplasty: A Matched Cohort Study

BACKGROUND

It is unclear if hepatitis C virus (HCV) negatively impacts outcomes of revision total hip arthroplasty (rTHA). The purpose of this study is to trend recent rTHA utilization in patients who have HCV and compare postoperative complication rates versus a matched cohort.

METHODS

All patients who underwent rTHA were retrospectively identified in a national database. Patients who had HCV (n = 1,746) were matched 1:3 with a matching group (n = 5,238) for age, gender, and several comorbidities. Cochran-Armitage tests were used to analyze trends in the annual proportion of rTHA performed in patients who had HCV from 2010 to 2019. Rates of 90-day medical and prosthesis-related complications within 2 years postoperatively were compared with multivariable logistic regressions.

RESULTS

The annual proportion of rTHA performed in patients who had HCV significantly increased from 2010 to 2019 (P < .001). Patients who had HCV exhibited significantly higher rates of acute kidney injuries (7.6% versus 4.4%; odds ratio [OR] 1.50), transfusions (20.6% versus 14.6%; OR 1.38), and re-revisions for prosthetic joint infection (10.9% versus 6.5%; OR 1.73). In subgroup analyses, rates of re-revision for prosthetic joint infection after initial aseptic rTHA (7.1% versus 3.8%; OR 1.82) and periprosthetic fracture after initial septic rTHA (4.5% versus 1.6%; OR 2.77) were significantly higher in the HCV cohort.

CONCLUSION

Similar to primary THA, patients who have HCV exhibit significantly increased complication rates after rTHA. With growing utilization in recent years, these data suggest that this population will comprise an increasingly larger proportion of rTHA procedures performed in the coming years.

Viral infections in orthopedics: A systematic review and classification proposal

BACKGROUND

Although the impact of microbial infections on orthopedic clinical outcomes is well recognized, the influence of viral infections on the musculoskeletal system might have been underestimated.

AIM

To systematically review the available evidence on risk factors and musculoskeletal manifestations following viral infections and to propose a pertinent classification scheme.

METHODS

We searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), the Reference Citation Analysis (RCA), and Scopus for completed studies published before January 30, 2021, to evaluate risk factors and bone and joint manifestations of viral infection in animal models and patient registries. Quality assessment was performed using SYRCLE's risk of bias tool for animal studies, Moga score for case series, Wylde score for registry studies, and Newcastle-Ottawa Scale for case-control studies.

RESULTS

Six human and four animal studies were eligible for inclusion in the qualitative synthesis. Hepatitis C virus was implicated in several peri- and post-operative complications in patients without cirrhosis after major orthopedic surgery. Herpes virus may affect the integrity of lumbar discs, whereas Ross River and Chikungunya viruses provoke viral arthritis and bone loss.

CONCLUSION

Evidence of moderate strength suggested that viruses can cause moderate to severe arthritis and osteitis. Risk factors such as pre-existing rheumatologic disease contributed to higher disease severity and duration of symptoms. Therefore, based on our literature search, the proposed clinical and pathogenetic classification scheme is as follows: (1) Viral infections of bone or joint; (2) Active bone and joint inflammatory diseases secondary to viral infections in other organs or tissues; and (3) Viral infection as a risk factor for post-surgical bacterial infection.

The Impact of Hepatitis C on Complication Rates After Revision Total Knee Arthroplasty: A Matched Cohort Study

Background

It is unclear if hepatitis C (HCV) negatively impacts outcomes of revision total knee arthroplasty (rTKA). The purpose of this study was to compare complication rates after rTKA for patients with HCV vs matched controls.

Methods

A retrospective cohort study was conducted using the PearlDiver database (PearlDiver Inc., Colorado Springs, CO). Patients with HCV who underwent rTKA (n = 1448) were matched 1:4 with controls (n = 5792) on age, sex, and several comorbidities. Rates of medical complications within 90 days and prothesis-related complications within 2 years postoperatively were compared with logistic regression for (1) patients with vs without HCV and (2) HCV patients who underwent aseptic vs septic rTKA.

Results

Relative to controls, patients with HCV exhibited significantly higher rates of medical complications (27.7% vs 20.9%; odds ratio [OR] 1.47), periprosthetic fractures (2.3% vs 1.1%; OR 2.20), all-cause repeat rTKA (11.7% vs 9.4%; OR 1.29), and repeat rTKA for prosthetic joint infection (PJI) (6.7% vs 3.6%; OR 1.92). Within the HCV cohort, HCV patients with initial septic rTKA exhibited significantly higher rates of medical complications (41.7% vs 22.7%; OR 2.39), all-cause subsequent rTKA (15.9% vs 10.2%; OR 1.67), and repeat rTKA for PJI (15.9% vs 3.4%; OR 5.39). Conversely, HCV patients with initial aseptic rTKA exhibited significantly higher rates of aseptic loosening (2.6% vs 7.4%; OR 0.33).

Conclusions

Patients with HCV exhibited significantly higher rates of medical and prosthesis-related complications after rTKA than controls. Among patients with HCV, initial septic rTKA was associated with significantly higher rates of medical complications, repeat rTKA, and PJI.

Total Joint Arthroplasty Should Not Be Delayed in Hepatitis C Patients After Successful Treatment Achieving a Sustained Viral Load

Background

Preoperative treatment recommendations and optimal time to perform total joint arthroplasty (TJA) in patients with hepatitis C virus after treatment completion for achieving best outcomes have not been elucidated. We aim to determine (1) if undetectable viral load (UVL) prior to TJA leads to decreased postoperative complication rates, specifically periprosthetic joint infection (PJI), and (2) if delaying TJA after treatment completion has benefit in decreasing PJI.

Methods

A retrospective review of all hepatitis C virus patients undergoing TJA at 3 academic tertiary care centers was conducted. A total of 270 TJAs performed from 2005 to 2019 were included, 125 with positive viral load at the time of surgery. The duration from completion of treatment regimen to TJA was recorded for the UVL cohort. The primary study outcome was PJI at 1-year follow-up. Secondary outcomes included in-hospital complications, mechanical revision TJA rates, and optimal time to TJA upon completion of treatment.

Results

Patients with positive viral load at the time of TJA had longer length of stay (3.9 vs 2.9 days, P < .0001) and a higher PJI rate at 1 year postoperatively (9% vs 2%, P = .02) than UVL patients. There was no difference of in-hospital complications or revision rates for mechanical etiologies. Delaying TJA after achieving a sustained virologic response did not impact PJI rates.

Conclusions

Sustained UVL prior to TJA is critical to minimize PJI irrespective of the treatment regimen utilized. Surgery can be performed with lower complication rates any time after achieving sustained virologic response.

Level of Evidence

Level III, prognostic retrospective cohort study.

Antiviral Treatment for Hepatitis C Is Associated With a Reduced Risk of Periprosthetic Joint Infection: A Meta-Analysis of Observational Studies

BACKGROUND

Recently, preoperative antiviral therapies for hepatitis C virus (HCV) have become available for total joint arthroplasty (TJA) patients. The objective of this meta-analysis is to investigate the impact of anti-HCV treatment on the incidence of postoperative complications after primary TJAs.

METHODS

We searched PubMed, EMBASE, Scopus, Web of Science, and Cochrane Library databases for relevant studies from inception to March 5, 2022. The pooled odds ratios with 95% CI of the risk of postoperative complications were calculated using the random effects model. Subgroup analyses were conducted on the basis of surgery type, antiviral regimes, and duration of follow-up.

RESULTS

Eight retrospective cohort studies fulfilled the inclusion and exclusion criteria, involving 9,703 subjects. Overall, antiviral therapy for HCV was associated with a reduced risk of all-type complications and surgical complications. Moreover, we found that HCV-infected patients without treatment had substantially higher rates of periprosthetic joint infection at any surgery type and follow-up time point. There was a tendency for favoring a lower pooled revision/reoperation rate and mechanical complication rate in treated patients compared with untreated patients, but the differences failed to reach statistical significance. When limiting analysis to patients receiving preoperative direct acting antiviral-based therapy, untreated patients still had a higher surgical complication rate and joint infection rate.

CONCLUSION

This meta-analysis demonstrated that antiviral therapy for HCV appears to be associated with a reduced risk of surgical complications in TJA patients, particularly periprosthetic joint infection. Thus, direct-acting antiviral therapy could be recommended for patients diagnosed with HCV.

Does Pre-Arthroplasty Antiviral Treatment for Hepatitis C Reduce Complication Rates After Total Shoulder Arthroplasty? A Matched Cohort Study

Background

Hepatitis C virus (HCV) is associated with increased complications of risk after arthroplasty. The purpose of this study was to examine the impact of HCV and a pre-arthroplasty antiviral treatment on complications following total shoulder arthroplasty (TSA).

Methods

A retrospective matched cohort study was conducted using an administrative claims database. Patients who underwent TSA were identified with Current Procedural Terminology -23472 and International Classification of Diseases procedural codes. A total of 1244 HCV patients were matched 1:3 with 3732 noninfected controls across age, sex, diabetes mellitus, tobacco use, and obesity. The HCV patients with treatment before TSA were identified by claims containing antiviral drug codes. Multivariable logistic regression was used to compare rates of 90-day medical complications and prosthesis-related complications within 2 years postoperatively for (1) HCV patients vs. controls, (2) antiviral-treated HCV patients vs. controls, and (3) antiviral-treated HCV patients vs. untreated HCV patients.

Results

Patients with HCV exhibited significantly higher rates of blood transfusion (OR 2.12), acute kidney injuries (OR 1.86), inpatient readmission (OR 2.06), revision TSA (OR 1.48), dislocation (OR 1.92), mechanical complications (OR 1.39), and prosthetic joint infection (OR 1.53) compared to controls. Antiviral-treated HCV patients exhibited a significantly lower rate of myocardial infarction (OR 0.27) and comparable rates of all other complications relative to controls (all P > .05). Compared to untreated HCV patients, antiviral-treated HCV patients exhibited significantly lower rates of 90-day medical complications (OR 0.57) and prosthetic joint infection (OR 0.36).

Conclusions

HCV is associated with significantly increased complication rates after TSA. Antiviral treatment before TSA may reduce the risk of postoperative complications.

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.

Does Preoperative Antiviral Treatment for Hepatitis C Decrease Risk of Complications After Total Hip Arthroplasty? A Matched Cohort Study

BACKGROUND

Hepatitis C virus (HCV) is associated with increased complication risk after elective arthroplasty. The purpose of this study is to examine the impact of HCV and prearthroplasty antiviral treatment on complications following total hip arthroplasty (THA).

METHODS

A retrospective matched cohort study was conducted using an administrative claims database. In total, 6,883 HCV patients were matched 1:3 with 20,694 noninfected controls, and 920 HCV patients with antiviral treatment before THA (treated HCV) were matched 1:4 with 3,820 HCV patients without treatment (untreated HCV). Rates of 90-day medical complications and joint complications within 2 years postoperatively were compared with multivariable logistic regression.

RESULTS

HCV patients exhibited significantly increased rates of medical complications within 90 days compared to noninfected controls (all P < .01). At 2 years postoperatively, HCV patients also exhibited significantly higher risk of revision THA (odds ratio [OR] 1.81), dislocation (OR 2.06), mechanical complications (OR 1.40), periprosthetic fracture (OR 1.76), and prosthetic joint infection (PJI) (OR 1.79). However, treated HCV patients exhibited statistically comparable risk of all joint complications at 2 years postoperatively relative to controls (all P > .05). Compared to untreated HCV patients, treated HCV patients exhibited significantly lower risk of inpatient readmission within 90 days (OR 0.58) and PJI at 2 years postoperatively (OR 0.62).

CONCLUSION

HCV patients exhibit significantly increased risk of medical and joint complications following THA relative to controls, though prearthroplasty antiviral treatment mitigates complication risk. Treated HCV patients exhibited significantly lower risk of inpatient readmission and PJI compared to untreated HCV patients.

LEVEL OF EVIDENCE

Level III.

Hepatitis C virus infection increases the risk of adverse outcomes following joint arthroplasty: A meta-analysis of observational studies

BACKGROUND

Whether hepatitis C virus (HCV)-positive patients are at risk for increased complications and long hospital stay following total joint arthroplasty (TJA) remains unclear. Therefore we performed a meta-analysis aiming to answer the following question: (1) are there differences in postoperative complications including joint infection and mortality between patients with or without hepatitis C following TJAs? (2) Are patients without HCV be associated with less blood loss, shorter hospital stay, lower readmission rate, higher function scores, lower revision and reoperation rates than patients with HCV?

METHODS

A meta-analysis was conducted to pool data and quantitatively assessing the association between HCV infection and risks for adverse postoperative outcomes. A systematic search of all published studies concerning HCV and TJA was performed in five bibliographic databases, including PubMed, EMBASE, China National Knowledge Infrastructure, Web of Science, and the Cochrane Library databases. Random-effects meta-analysis of odds ratios (OR) was accomplished according to the classification of adverse events, subgroup analyses were performed based on surgery type.

RESULTS

Fifteen eligible observational studies were included with a sample size of 9,788,166 patients. Overall pooled data revealed the increased risk of overall complications, including medical and surgical complications, in HCV-positive patients undergoing TJA compared with than in HCV-negative people (OR 1.57; 95%CI: 1.44-1.71 [p<0.00001]). Joint infections were highly common in HCV-positive patients undergoing lower-extremity TJA (OR 2.06; 95%CI: 1.73-2.47 [p<0.00001]). Furthermore, HCV infections were associated with high rates of reoperations and revisions (OR 1.47; 95%CI: 1.40-1.55 [p<0.00001]).

CONCLUSIONS

Patients with hepatitis C have an increased risk of adverse outcomes post-TJA and a high risk of reoperation and revision that is partially attributed to postoperative complications, particularly joint infections.

LEVEL OF EVIDENCE

III; systematic review and meta-analysis.

Hepatitis C infection and complication rates after total shoulder arthroplasty in United States veterans

Background

Few studies have evaluated the effect of hepatitis C (HCV) on primary total shoulder arthroplasty (TSA). Our purpose was to determine if HCV infection is associated with increased complication rates after TSA in United States (US) veterans and, secondarily, to determine if preoperative HCV treatment with direct-acting antivirals (DAAs) affects postoperative complication rates.

Methods

US Department of Veterans Affairs (VA) data sets were used to retrospectively identify patients without HCV, patients with untreated HCV, and patients with HCV treated with DAAs who underwent TSA from 2014 to 2019. Medical and surgical complications were assessed using International Classification of Diseases codes. Complication rates between patients with HCV (treated and untreated) and patients without HCV and between HCV-treated patients and HCV-untreated patients were compared at 90 days and 1 year after surgery.

Results

We identified 5774 primary TSAs that were performed at VA hospitals between 2014 and 2019. A minority (9.5%) of TSA patients had HCV, 23.4% of whom were treated preoperatively with DAAs. On multivariate analysis, HCV patients had increased odds of 1-year medical complications (odds ratio, 1.39; 95% confidence interval, 1.06-1.81, P = .016), when compared with patients without HCV. No statistically significant difference in complication rates was observed between HCV-treated and HCV-untreated patients.

Discussion

US veterans with a history of HCV are at an increased risk of developing medical but not surgical complications within the first year after TSA. Larger studies are necessary to evaluate the effects of DAA treatment on complication rates.

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.

Coinfection of HIV and hepatitis C increases complication rates after total joint arthroplasty

INTRODUCTION

As advances in efficacy of human immunodeficiency virus (HIV) and hepatitis-C virus (HCV) anti-viral medications increase, patients are able to maintain higher quality of lives than ever before. While these patients live longer lives, the unique patient population of those co-infected with both HIV and HCV increases. As these older patients seek orthopaedic care, it is important to understand their unique outcome profile. The purpose of this study was to evaluate the complication rate after total joint arthroplasty (TJA) in patients with HIV and HCV coinfection compared with patients with HIV or HCV only.

METHODS

A retrospective review of patients undergoing primary total joint arthroplasty (TJA) at our urban, academic hospital between April 2016 and April 2019 was conducted. Patients were stratified into three groups according to viral status: HIV only, HCV only, or HIV and HCV coinfection. Baseline demographics, intravenous drug (IV) use, surgery type, CD4+ count, follow-up and complications were analysed.

RESULTS

Of the 133 patients included in the study, 28 had HIV, 88 had HCV and 17 were coinfected with both HIV and HCV. Coinfected patients were more likely to have a lower BMI (p < 0.039) and a history of IV drug use (p < 0.018) compared to patients with either HIV or HCV only. Coinfected patients had a higher complication rate (41%) than both HIV only (7%; p < 0.001) and HCV only (12.5%; p < 0.001) patients.

DISCUSSION

Patients coinfected with HIV and HCV undergoing TJA have a higher complication rate than patients with either infection alone. As this unique population of coinfected patients continues to expand, increasingly they will be under the care of arthroplasty surgeons. Improved awareness and understanding of the baseline demographic differences between these patients is paramount. Recognition of the increased complication rates grants the opportunity to improve their orthopaedic care through preoperative and multidisciplinary management.

Hepatitis C Virus Infection as a Predictor of Complications and Increased Costs Following Primary Lumbar Fusion Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to identify whether hepatitis C virus (HCV) diagnosis influences in-hospital lengths of stay (LOS), postoperative complications, readmission rates, or costs following primary posterior lumbar fusions in an elective setting.

SUMMARY OF BACKGROUND DATA

Although joint arthroplasty literature has shown increased complication rates and costs for patients seropositive with HCV without liver disease compared to those without HCV, this comorbidity has not been explored in the spine literature. To our knowledge, this is the first publication in the lumbar spine literature to solely focus on HCV as the disease burden.

METHODS

A national database was queried for patients who underwent primary lumbar spine fusion for degenerative lumbar pathology with Medicare insurance from 2005 to 2014. The 90-day postoperative complication rates, readmission rates, and treatment costs were queried. To limit confounding, HCV patients were matched with a control cohort of non-HCV patients using patient demographics, treatment modality, and comorbid conditions, and then analyzed by multivariate logistic regression. Patients with active liver disease were excluded to better isolate HCV as the comorbidity.

RESULTS

A cohort of 28,841 patients were included in the final analysis. Postoperatively, compared to those without HCV infection, those with HCV had significantly higher odds of blood transfusions (odds ratio [OR]: 3.06), pneumonia (OR: 2.49), respiratory failure (OR: 2.49), urinary tract infections (OR: 1.89), wound-/implant-related infections (OR: 1.74), cerebrovascular events (OR: 1.70), or any postoperative complication within 90 days (OR: 2.93; all P < 0.0001). Furthermore, HCV positive patients had higher day of surgery costs ($28,713.26 vs. $25,448.26, P < 0.0001) and 90-day costs ($33,447.39 vs. $29,016.77, P < 0.0001). There was not a significant difference for patients with HCV infection compared to those without in regard to hospital LOS (10 days vs. 8 days, P = 0.332) and rates of a 90-day readmission (0.37% vs. 0.22%; OR: 1.70, 95% confidence interval: 1.00-2.90, P: 0.050).

CONCLUSION

In patients undergoing primary lumbar fusion, a seropositivity for HCV without liver disease is associated with higher costs and complication rates, including higher rates of blood transfusion requirements and pneumonia-related complications. This data shed new light on elective spine surgery in HCV patients and may influence the risks and benefits considerations for surgeons considering lumbar fusion in this population.

LEVEL OF EVIDENCE

3.

Ankle fusion in patients with chronic hepatitis C

BACKGROUND

It appears that both the incidence and survival of patients infected with hepatitis C have recently demonstrated a significant increase. The goal of this investigation was to determine the associated perioperative risks associated with ankle arthrodesis in this growing population.

METHODS

The Healthcare Cost and Utilization Project State Inpatient Databases identified patients with chronic hepatitis C infection who underwent ankle arthrodesis between January 2009 and December 2013. International Classification of Diseases, Ninth Revision, codes were used to define the primary composite outcome of death or postoperative complication. Logistic models with frequency weights were used to compare propensity matched groups.

RESULTS

7339 patients met inclusion criteria. Of these, 157 patients had a history of chronic Hepatitis C infection. After performing a propensity score match, the final analytic cohort was 157 in the Hepatitis C group and 386 in the non-Hepatitis C group. There was no statistically significant differences in complications between patients with chronic Hepatitis C undergoing ankle fusion and those without Hepatitis C at any post-operative time point (inpatient, 30 days, or 90 days).

DISCUSSION

Patients with chronic hepatitis C infection undergoing ankle arthrodesis are not at an elevated risk of inpatient, thirty, and ninety day postoperative complications compared to patients without chronic HCV infections. Patients with chronic hepatitis C did not have an increased risk of surgical site infection or mortality at any time point.

LEVEL OF EVIDENCE

Prognostic Level III.

Does the hepatitis C virus affect the outcomes of total joint arthroplasty? A meta-analysis of ten studies

BACKGROUND

It is estimated that 3%-8% of orthopedic patients, many of whom may undergo lower extremity total joint arthroplasty (TJA), are infected with hepatitis C virus. However, the impact of this virus on total joint arthroplasty is still undefined.

METHODS

Eligible studies were searched from electronic databases including PubMed, Web of Science, CNKI and OVID. Two researchers performed data extraction from eligible independently. Quality parameters and risk of bias in the included studies were assessed according to Cochrane's guidelines. The pooled Standardized Mean Difference (SMD) with a 95%CI was used to assess the outcomes of total joint arthroplasty in patients with the hepatitis C virus.

RESULTS

A total of 28 articles related to hepatitis C virus and total joint arthroplasty were reviewed. All clinical studies were eliminated and six articles containing ten studies eventually satisfied the eligibility criteria for this study. The pooled analysis showed hepatitis C had a higher complications rate than non-hepatitis C, with the pooled HR values of 1.55 (95%CI = 1.11-2.17, p = 0.01). As for THA, an overall pooled HR value (HR = 2.21, 95%CI = 1.19-4.10, p = 0.012) was obtained, indicating that patients with hepatitis C virus had a higher revision rate than non-hepatitis C. The infection rate was different between hepatitis C patients and non-hepatitis C controls (HR = 1.29, 95% = 1.17-1.44, P = 0.00). The combined analysis revealed a significantly longer length of hospital stay in patients with hepatitis C virus (HR = 0.88, 95%CI = 0.54-1.21, p = 0.000).

CONCLUSIONS

This is the first systematic review and meta-analysis investigating the impact of hepatitis virus on total joint arthroplasty. Based on this meta-analysis, we can draw a conclusion that the patients with hepatitis C virus have higher rates of complication, infection, and revision compared to patients with non-hepatitis virus. Besides, hepatitis C infected patients require a significant longer hospital stay than patients without hepatitis.

Preoperative Treatment of Hepatitis C Is Associated With Lower Prosthetic Joint Infection Rates in US Veterans

BACKGROUND

Hepatitis C virus (HCV) is associated with poorer outcomes in total joint arthroplasty (TJA). Recently, oral direct-acting antivirals (DAAs) have become available for HCV curative treatment. The goal of this study is to determine if HCV may be a modifiable risk factor in TJA by comparing postoperative complications among patients with and without preoperative treatment for HCV.

METHODS

US Department of Veterans Affairs dataset of all consecutive primary TJAs performed between 2014 and 2018, when DAAs were available, was retrospectively reviewed. HCV-infected patients were identified using International Classification of Diseases, Ninth and Tenth Revision codes and laboratory values. HCV-infected patients treated prior to TJA with DAA were included in the "treated" group. HCV-infected patients untreated preoperatively were assigned to the "untreated" group. Medical and surgical complications up to 1 year postoperatively were identified using International Classification of Diseases, Ninth and Tenth Revision inpatient and outpatient codes.

RESULTS

In total, 42,268 patients underwent TJA at Veterans Affairs Hospitals between 2014 and 2018. About 6.0% (n = 2557) of TJA patients had HCV, 17.3% of whom received HCV treatment preoperatively. When evaluating inpatient and outpatient codes, implant infection rates were statistically lower at 90 days and 1 year postoperatively among HCV-treated patients than among those untreated. Odds ratios (ORs) favor lower infection rates in HCV-treated patients (90-day OR: 3.30, P = .045; 1-year OR: 2.16, P = .07).

CONCLUSION

Preoperative HCV treatment was associated with lower periprosthetic infection rates among US veterans undergoing TJA. Further investigation is necessary for definitive conclusions.

The Effects of Liver Disease on Surgical Outcomes Following Adult Spinal Deformity Surgery

BACKGROUND

As the prevalence of chronic liver disease continues to rise in the United States, understanding the effects of liver dysfunction on surgical outcomes has become increasingly important. The objective of this study was to assess the effects of chronic liver disease on 30-day complications following adult spinal deformity (ASD) surgery.

METHODS

We performed a retrospective cohort study of 2337 patients in the 2008-2015 American College of Surgeons National Surgical Quality Improvement Program database who underwent corrective ASD surgery. Patients with liver disease were identified based on a Model for End-Stage Liver Disease-Na score ≥10. A univariate analysis was performed to compare 30-day postoperative complications between patients with and without liver disease. A multivariate regression analysis adjusting for differences in baseline patient characteristics was performed to identify complications that were associated with liver disease.

RESULTS

Patients with liver disease had a significantly greater incidence of postoperative pulmonary complications (6.3% vs. 2.9%; P < 0.001), blood transfusion (34.6% vs. 24.0%; P < 0.001), sepsis (2.2% vs. 0.9%; P = 0.011), prolonged hospitalization (19.0% vs. 8.0%; P < 0.001), as well as any 30-day complication (45.4% vs. 29.4%; P < 0.001). The multivariate regression analysis identified liver disease as a risk factor for prolonged hospitalization (odds ratio [OR] 2.16; 95% confidence interval [CI] 1.64-2.84; P < 0.001), pulmonary complications (OR 1.78; 95% CI 1.16-2.74; P = 0.009), blood transfusion (OR 1.67; 95% CI 1.36-2.05; P < 0.001), and any 30-day complication (OR 1.43; 95% CI 1.15-1.77; P = 0.001).

CONCLUSIONS

The multisystem pathophysiology of liver dysfunction predisposes patients to postoperative complications following ASD surgery. A multidisciplinary approach in surgical planning and preoperative optimization is needed to minimize liver disease-related complications and improve patient outcomes.

The preoperative management of Hepatitis C may improve the outcome after total knee arthroplasty

AIMS

With an ageing population of patients who are infected with hepatitis C virus (HCV), the demand for total knee arthroplasty (TKA) in this high-risk group continues to grow. It has previously been shown that HCV infection predisposes to poor outcomes following TKA. However, there is little information about the outcome of TKA in patients with HCV who have been treated successfully. The purpose of this study was to compare the outcomes of TKA in untreated HCV patients and those with HCV who have been successfully treated and have a serologically confirmed remission.

PATIENTS AND METHODS

A retrospective review of all patients diagnosed with HCV who underwent primary TKA between November 2011 and April 2018 was conducted. HCV patients were divided into two groups: 1) those whose HCV was cured (HCV-C); and 2) those in whom it was untreated (HCV-UT). All variables including demographics, HCV infection characteristics, surgical details, and postoperative medical and surgical outcomes were evaluated. There were 64 patients (70 TKAs) in the HCV-C group and 63 patients (71 TKAs) in the HCV-UT cohort. The mean age at the time of surgery was 63.0 years (sd 7.5; 44 to 79) in the HCV-C group and 61.7 years (sd 6.9; 47 to 88) in the HCV-UT group.

RESULTS

HCV-UT patients had a significantly longer mean hospital stay (3.4 days vs 2.9 days; p = 0.04), were more likely to be transferred to the intensive care unit (14.1% vs 4.3%; p = 0.04), and were significantly more often discharged to a post-acute care facility (39.4% vs 14.3%; p < 0.01). HCV-UT patients had significantly more postoperative infections (15.5% vs 4.3%; p = 0.03), surgical complications (21.1% vs 7.1%; p = 0.02), and revision TKA (12.7% vs 1.4%; p < 0.01) than HCV-C patients.

CONCLUSION

The preoperative treatment of HCV can reduce the risk of complications, including prosthetic joint infection and revision TKA. We recommend that HCV treatment regimens should be integrated into the preoperative optimization protocol for this high-risk group of patients. Cite this article: Bone Joint J 2019;101-B:667-674.

Association of hepatitis B infection with high-risk complications in total joint arthroplasty

Background

An increasing number of patients with hepatitis B virus (HBV) infection are undergoing total joint arthroplasty (TJA) surgery in China. Less attention is provided to the special populations and the purpose of this study is to assess the effect of HBV infection on the prognosis TJAs.

Methods

We retrospectively reviewed patients who underwent elective primary hip and knee arthroplasties in Shanghai Huashan Hospital from 2013 to 2016. Non-hepatitis B cohort was built to match the case cohort to identify whether HBV infection was a risk factor associated with postoperative complications. A total number of 196 patients who underwent primary TJAs were involved in the study, including 49 patients with hepatitis B and 147 non-hepatitis B subjects.

Results

Among all the patients with TJAs, 5.5% of patients were infected with HBV for the first time. The incidence rate of complications in patients after arthroplasty with hepatitis B infection was significantly higher than that in patients without hepatitis B (10.2% compared to 4.7%, P < 0.01). Surgical related complications (6.1% compared to 3.4%) and general medical complications (4.1% compared to 1.3%) were higher than those in non-B hepatitis group. Compared with non-B hepatitis group, the overall risk of hepatitis B infection increased by 25% (95% CI, 1.04–1.46; p < 0.01). Similar results were obtained for medical and surgical complications. HBV infection presented a 31% increased risk (95% CI, 1.02–1.62; p < 0.01) for medical complication and an 18% increased risk (95% CI, 1.10–1.26; p < 0.01) for surgical complication. No statistical difference was found between the surgical methods and sex. However, a significant difference of C-reactive protein (CRP) level was found between HBV infection group and the matched non-infected group (P < 0.01).

Conclusion

This is the first study to investigate the risk of perioperative complications of hepatitis B in Chinese TJAs patients. In consideration of the large population of HBV infection in China, more attention and medical care should be provided to patients with HBV infection who need to undergo TJA operation.

Treatment for Chronic Hepatitis C Prior to Total Hip Arthroplasty Significantly Reduces Periprosthetic Joint Infection

BACKGROUND

Patients with chronic hepatitis C (HCV) have had extremely high complication rates after total hip arthroplasty (THA). We sought to compare perioperative complication rates between untreated and treated HCV in THA patients and to compare these rates between patients treated with 2 different therapies (interferon vs direct antiviral agents).

METHODS

A multicenter retrospective database query was used to identify patients diagnosed with HCV who underwent THA between 2006 and 2016. All patients (n = 105) identified were included and divided into 2 groups: untreated (n = 63) and treated (n = 42) HCV; treated patients were further subdivided into those receiving interferon (n = 16) or direct antiviral agent therapies (n = 26). Comparisons between the treated and untreated groups were made with respect to demographic data, comorbidities, preoperative viral load, Model for End-Stage Liver Disease score, and all surgical and medical complications; a subgroup analysis of the treated patients was also performed. Separate independent t-tests or Mann-Whitney U tests were conducted for continuous variables. Categorical variables were compared using the chi-squared test of independence.

RESULTS

A greater number of untreated patients were human immunodeficiency virus infected (P = .01), while a reduced number of treated patients were either former or current smokers (P = .004). The untreated group had greater surgical complication rates (25.4% vs 4.8%; P = .007), with a higher rate of periprosthetic joint infection (14.3% vs 0%, P = .01). For treated patients, no differences were observed between treatment types for postsurgical complications.

CONCLUSION

Treatment for HCV prior to THA appears to be associated to fewer postoperative complications, primarily periprosthetic joint infection. Although further investigation is warranted, strong consideration should be given to treating patients for HCV prior to elective THA.

Hepatitis C is an Independent Risk Factor for Perioperative Complications and Nonroutine Discharge in Patients Treated Surgically for Hip Fractures

OBJECTIVE

To evaluate the relationship between noncirrhotic hepatitis C virus (HCV) infection, perioperative complications, and discharge status in patients undergoing surgical procedures for hip fractures.

METHODS

A retrospective epidemiological study was performed, querying the National Hospital Discharge Survey. Patients were selected using the International Classification of Diseases-9 diagnostic codes for hip fracture and primary procedural codes for open reduction internal fixation, hemiarthroplasty, total hip arthroplasty, or internal fixation. Patients with concurrent cirrhosis, HIV, hepatitis A, B, D, or E were excluded. Pearson χ tests, independent-samples t test, and multivariable binary logistic regression were used for data analysis.

RESULTS

Two cohorts surgically treated for a hip fracture were identified and compared. The first cohort included 5377 patients with a concurrent diagnosis of noncirrhotic HCV infection (HCV+) and the second included 4,712,159 patients without a diagnosis of HCV (HCV-). The HCV+ cohort was younger and had fewer medical comorbidities, yet was found to have a longer length of hospital stay, higher rates of nonroutine discharge, and higher rates of complications than the HCV- cohort. Multivariate regression analysis demonstrated that HCV+ is an independent risk factor for perioperative complications and nonroutine discharge.

CONCLUSIONS

In conclusion, our study demonstrates a negative association between noncirrhotic HCV infection and hip fracture surgery outcomes. Caution and appropriate preparation should be taken when surgically treating hip fractures in HCV+ patients because of higher risk of perioperative complications and nonroutine discharge.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Short and Long-Term Postoperative Complications Following Total Joint Arthroplasty in Patients With Human Immunodeficiency Virus, Hepatitis B, or Hepatitis C

INTRODUCTION

Due to advancement in treatment against human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), the prevalence of this patient population electing to undergo total joint arthroplasty (TJA) is increasing. Current literature is scarce and conflicting especially when evaluating long-term surgical complications. The purpose of this study is to assess the postoperative medical and surgical complications following TJA in these patient populations.

METHODS

Using a nationwide database between 2005 and 2012, 4 cohorts were created: patients with HIV, HCV, HBV, and HIV and HBV or HCV who underwent TJA. Cohorts were matched to a control group by age, gender, and Charlson Comorbidity Index. Thirty-day and 90-day medical complications and 90-day and 2-year surgical complications were evaluated using odds ratios with 95% confidence intervals.

RESULTS

Following TJA, patients with HCV or HBV had increased risk of pneumonia, sepsis, joint infection, and revision surgery at 90 days and 2 years. Patients with HIV did not have increased risk of infection at 90 days and 2 years but did have increased risk of revision at 90 days (odds ratio 3.21, 95% confidence interval 1.31-7.84) following total hip arthroplasty.

CONCLUSIONS

Patients with HIV, HBV, or HCV have an overall increased risk of postoperative medical and surgical complications following TJA. Patients with HBV or HCV are at risk of more complications than patients with HIV especially for infection within 90 days after TJA. Patients with HIV are at risk of mechanical complications but do not appear to be at significant risk for infection following total hip arthroplasty.

Opioid Use Disorders Are Associated With Perioperative Morbidity and Mortality in the Hip Fracture Population

OBJECTIVES

To determine whether opioid use disorders (OUDs) are associated with adverse perioperative outcomes in patients undergoing surgical fixation for proximal femur fractures.

METHODS

The National Hospital Discharge Survey was queried to identify patients surgically treated for proximal femur fractures between 1990 and 2007. Patients were grouped into those with a diagnosis of OUD, nonopioid drug use disorder, or neither. Demographic information and comorbidities were included in univariable and multivariable analyses to identify independent risk factors for perioperative outcomes.

RESULTS

A total of 8154 patients with a diagnosis of drug use disorder and 4704 patients with a diagnosis of OUD were identified from a cohort of 4,732,165 surgically treated proximal femur fractures. Patients with OUD were significantly younger (46 vs. 79), and a significantly smaller proportion of them had medical comorbidities (21.9% vs. 60.2%) when compared with the no drug misuse cohort. Patients with OUD had significantly more medical complications (51.1% vs. 26.8%), mechanical complications (3% vs. 0.3%), and adverse events (55% vs. 39.7%) when compared with the no drug misuse group. OUD had higher odds for leaving against medical advice [odds ratio (OR) 12.868, range 10.7771-15.375], for any adverse event (OR 4.107, range 3.869-4.360), and for mortality (OR 1.744, range 1.250-2.433) when compared with nondrug misusers.

CONCLUSIONS

Despite being younger and with significantly less medical comorbidities, patients with OUD have higher odds for adverse events, leaving against medical advice, and mortality after surgical treatment of a hip fracture.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hepatitis C Virus Infection and Risk of Venous Thromboembolism: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

Hepatitis C virus (HCV) infection is one of the leading causes of cirrhosis. As a result of chronic inflammatory response to the virus, HCV-infected patients may be at a higher risk of venous thromboembolism (VTE). However, the data on this association is unclear. This systematic review and meta-analysis was conducted with the aims to summarize all available evidence.

MATERIAL AND METHODS

A literature search was performed using MEDLINE and EMBASE from inception to April 2016. Studies that reported relative risks, odd ratios, or hazard ratios comparing the risk of VTE among HCV-infected patients vs. subjects without HCV infection were included. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.

RESULTS

Three studies met our eligibility criteria and were included in analysis. The pooled RR of VTE in HCV-infected patients vs. subjects without HCV infection was 1.38 (95% CI, 1.08-1.77, I2 = 40%). Subgroup analysis showed that risk was increased for both pulmonary embolism (PE) and deep venous thrombosis (DVT) even though without adequate power to demonstrate statistical significance (Pooled RR of 1.34, 95% CI, 0.67-2.66 for PE and pooled RR 1.45, 95% CI, 0.93-2.77 for DVT).

CONCLUSION

Our study demonstrated a significantly increased risk of VTE among HCV-infected patients. Further studies are required to clarify how this risk should be addressed in clinical practice.

Hypothyroidism Increases 90-Day Complications and Costs Following Primary Total Knee Arthroplasty

BACKGROUND

Thyroid disease is common and often remains undetected in the US population. Thyroid hormone has an array of metabolic, immunologic, and musculoskeletal functions crucial to well-being. The influence of thyroid disease on perioperative outcomes following primary total knee arthroplasty (TKA) is poorly understood. We hypothesized that hypothyroidism was associated with a higher risk of postoperative complications and 90-day costs following primary TKA.

METHODS

The Medicare standard analytical files were queried using International Classification of Disease codes between 2005 and 2014 to identify patients undergoing primary TKA. Patients with a diagnosis of hypothyroidism were matched by age and gender on a 1:1 ratio. Ninety-day postoperative complication rates, day of surgery, and 90-day global period charges and reimbursements were compared between matched cohorts.

RESULTS

A total of 2,369,594 primary TKAs were identified between 2005 and 2014. After age and gender matching, each cohort consisted of 98,555 patients. Hypothyroidism was associated with greater odds of postoperative complications compared to matched controls (odds ratio 1.367, 95% confidence interval 1.322-1.413). The 90-day incidence of multiple postoperative medical and surgical complications, including periprosthetic joint infection, was higher among patients with hypothyroidism. Day of surgery and 90-day episode of care costs were significantly higher in the hypothyroidism cohort.

CONCLUSION

This study demonstrated an increased risk of multiple postoperative complications and higher costs among patients with hypothyroidism following primary TKA. Surgeons should counsel patients on these findings and seek preoperative optimization strategies to reduce these risks and lower costs in this patient population.

Operative Trends in the Treatment of Hip Fractures and the Role of Arthroplasty

Introduction:

There is a projected exponential increase in the number of hip fractures in the United States. Trends in patient demographics and the role of total hip arthroplasty (THA) and its associated outcomes following hip fractures surgery have not been well studied.

Methods:

Patients with proximal femur fractures between 1990 and 2007 were identified in the National Hospital Discharge Survey database. Demographics, comorbidities, perioperative complications, and discharge status for patients undergoing THA, hemiarthroplasty, or internal fixation were examined. Multivariable regression was performed to determine independent risk factors for perioperative complications.

Results:

Between 1990 and 2007, there was a statistically significant increase in patient age, adverse events, medical comorbidities, surgical complications, medical complications, and nonroutine discharge across all surgical treatment modalities. In the same time period, the utilization of THA for all fracture types decreased significantly.

Discussion:

Total hip arthroplasty was found to be an independent risk factor for perioperative complications. Orthopedic surgeons should be aware that the hip fracture population continues to get older, with more medical comorbidities and are at higher risk for perioperative complications.

Conclusion:

Total hip arthroplasty is associated with a higher rate of perioperative complications in the hip fracture population.

The Risks of Hepatitis C in Association With Cervical Spinal Surgery: Analysis of Radiculopathy and Myelopathy Patients

STUDY DESIGN

Retrospective review.

OBJECTIVE

To investigate rates of in-hospital postsurgical complications among hepatitis C-infected patients after cervical spinal surgery in comparison with uninfected patients and determine independent risk factors.

SUMMARY OF BACKGROUND DATA

Studying hepatitis C virus (HCV) as a possible risk factor for cervical spine postoperative complications is prudent, given the high prevalence of cervical spondylosis and HCV in older patients. Spine literature is limited with respect to the impact of chronic HCV upon complications after surgery.

MATERIALS AND METHODS

Patients who underwent cervical spine surgery for cervical radiculopathy (CR) or cervical myelopathy (CM) from 2005 to 2013 were retrospectively reviewed using the Nationwide Inpatient Sample database. Patients were divided into CR and CM groups, with comparative subgroup analysis of HCV and no-HCV patients. Univariate analysis compared demographics and complications. Binary logistic stepwise regression modeling identified any independent outcome predictors (covariates: age, sex, Deyo score, and surgical approach).

RESULTS

In total, 227,310 patients (HCV: n=2542; no-HCV: n=224,764) were included. From 2005 to 2013, HCV infection prevalence among all cervical spinal fusion cases increased from 0.8% to 1.2%. HCV patients were more likely to be African American or Hispanic and have Medicare and/or Medicaid (all P<0.001). Overall complication rates among HCV patients with CR or CM increased, specifically related to device (CR: 3.1% vs. 1.9%; CM: 2.9% vs. 1.3%), hematoma/seroma (CR: 1.1% vs. 0.4%; CM: 1.8% vs. 0.8%), and sepsis (CR: 0.4% vs. 0.1%; CM: 1.1% vs. 0.5%) (all P≤0.001). Among CR and CM patients, HCV significantly predicted increased complication rates [odds ratio (OR): 1.268; OR: 1.194], hospital stay (OR: 1.738; OR: 1.861), and hospital charges (OR: 1.516; OR: 1.732; all P≤0.044).

CONCLUSIONS

HCV patients undergoing cervical spinal surgery were found to have increased risks of postoperative complications and increased risk associated with surgical approach. These findings should augment preoperative risk stratification and counseling for HCV patients and their spine surgeons.

LEVEL OF EVIDENCE

Level III.

Risk of Complications After THA Increases Among Patients Who Are Coinfected With HIV and Hepatitis C

BACKGROUND

Individuals coinfected with both hepatitis C virus (HCV) and HIV represent a unique and growing population of patients undergoing orthopaedic surgical procedures. Data regarding complications for HCV monoinfection or HIV monoinfection are robust, but there are no data available, to our knowledge, on patients who have both HCV and HIV infections.

QUESTIONS/PURPOSES

We sought to determine whether patients with coinfection differed in terms of baseline demographics and comorbidity burden as compared with patients without coinfection and whether these potential differences were translated into varying levels of postoperative complications, mortality, and hospital readmission risk. Specifically, we asked: (1) Are there demonstrable differences in baseline demographic variables between patients infected with HCV and HIV and those who do not have those infections (age, sex, race, and insurance status)? (2) Do patients with HCV and HIV infection differ from patients without those infections in terms of other medical comorbidities? (3) Do patients with HCV/HIV coinfection have a higher incidence of early postoperative complications and mortality than patients without coinfection? (4) Is the frequency of readmission greater for patients with HCV/HIV coinfection than those without?

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) database was used to identify patients undergoing THA between 2010 and 2014. The SPARCS database is particularly useful because it captures 100% of all New York State inpatient admissions while providing detailed demographic and comorbidity data for a large, heterogeneous patient population with long-term followup. Patients were stratified into four groups based on HCV/HIV status: control patients without disease, HCV monoinfection, HIV monoinfection, and coinfection. We sought to determine whether patients coinfected with HCV and HIV would differ in terms of demographics from patients without those infections and whether patients with HCV and HIV would have a greater risk of complications, longer length of stay, and hospital readmission. A total of 80,722 patients underwent THA between 2010 and 2014. A total of 98.55% (79,554 of 80,722) of patients did not have either HCV or HIV, 0.66% (530 of 80,722) had HCV monoinfection, 0.66% (534 of 80,722) HIV monoinfection, and 0.13% (104 of 80,722) were coinfected with both HCV and HIV. Multivariate analysis was performed controlling for age, sex, insurance, residency status, diagnosis, and comorbidities to allow for an equal comparison between groups.

RESULTS

Patients with coinfection were more likely to be younger, male (odds ratio [OR], 2.90; 95% confidence interval [CI], 2.20-3.13; p < 0.001), insured by Medicaid (OR, 6.43; 4.41-7.55; p < 0.001), have a history of avascular necrosis (OR, 8.76; 7.20-9.53; p < 0.001), and to be homeless (OR, 6.95; 5.31-7.28; p < 0.001) as compared with patients without HIV or HCV. Additionally, patients with coinfection had the highest proportion of alcohol abuse, drug abuse, and tobacco use along with a high proportion of psychiatric disorders, including depression. HCV and HIV coinfection were independent risk factors for increased length of stay (OR, 1.97; 95% CI, 1.29-3.01; p < 0.001), having two or more in-hospital complications (OR, 1.64; 1.01-2.67; p < 0.001), and 90-day readmission rates (OR, 2.97; 1.86-4.77; p < 0.001).

CONCLUSIONS

As the prevalence of HCV and HIV coinfectivity continues to increase, orthopaedic surgeons will encounter a greater number of these patients. Awareness of the demographic and socioeconomic factors leading to increased complications after THA will allow physicians to consider interventions such as in-hospital psychiatric counseling, advanced discharge planning, and coordination with social work and collaboration with HCV/HIV infectious disease specialists to improve patient health status to improve outcomes and reduce costs.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Season of the year influences infection rates following total hip arthroplasty

AIM

To research the influence of season of the year on periprosthetic joint infections.

METHODS

We conducted a retrospective review of the entire Medicare files from 2005 to 2014. Seasons were classified as spring, summer, fall or winter. Regional variations were accounted for by dividing patients into four geographic regions as per the United States Census Bureau (Northeast, Midwest, West and South). Acute postoperative infection and deep periprosthetic infections within 90 d after surgery were tracked.

RESULTS

In all regions, winter had the highest incidence of periprosthetic infections (mean 0.98%, SD 0.1%) and was significantly higher than other seasons in the Midwest, South and West (P < 0.05 for all) but not the Northeast (P = 0.358). Acute postoperative infection rates were more frequent in the summer and were significantly affected by season of the year in the West.

CONCLUSION

Season of the year is a risk factor for periprosthetic joint infection following total hip arthroplasty (THA). Understanding the influence of season on outcomes following THA is essential when risk-stratifying patients to optimize outcomes and reduce episode of care costs.

Complication Rates After Total Hip and Knee Arthroplasty in Patients With Hepatitis C Compared With Matched Control Patients

BACKGROUND

A paucity of data exists regarding long-term outcomes among patients with hepatitis C who undergo total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

We queried a database for patients with hepatitis C who underwent THA and TKA. We then identified their rates of several postoperative complications and compared them with the same rates among mutually exclusive matched control cohorts.

RESULTS

Patients with hepatitis C who underwent THA and TKA had higher rates of infection, aseptic revision surgery, medical complications, and blood transfusion compared with matched control patients.

DISCUSSION

Our findings suggest that patients with hepatitis C who undergo THA and TKA are at increased risk of experiencing several postoperative complications, which could mean a substantial increase in the cost of care.

CONCLUSIONS

Further research is needed to establish quantifiable associations between hepatitis C and postoperative complications among patients with the disease who undergo total joint arthroplasty.

The risk of venous thromboembolism in patients with hepatitis C

Some studies suggest that patients with hepatitis C virus (HCV) infection have an increased risk of deep venous thrombosis (DVT) and pulmonary embolism (PE). Unfortunately, available data on this association are contrasting. A systematic review and meta-analysis of literature studies was performed to evaluate the risk of venous thromboembolism (VTE) associated with HCV. Studies reporting on VTE risk associated with HCV were systematically searched in the PubMed, Web of Science, Scopus and EMBASE databases. Six studies (10 data-sets) showed a significantly increased VTE risk in 100,364 HCV patients as compared with 8,471,176 uninfected controls (odds ratio [OR]: 1.900; 95 % confidence interval [CI]: 1.406, 2.570; p<0.0001). These results were confirmed when specifically considering the risk of DVT (6 studies, OR: 1.918; 95 %CI: 1.351, 2.723; p<0.0001), whereas a trend towards an increased risk of PE was documented in HCV patients (4 studies, OR: 1.811; 95 %CI: 0.895, 3.663; p=0.099). The increased VTE risk associated with HCV infection was consistently confirmed when analysing four studies reporting adjusted risk estimates (OR: 1.876; 95 %CI: 1.326, 2.654; P<0.0001), and after excluding studies specifically enrolling populations exposed to transient risk factors for VTE (4 studies, OR: 1.493; 95 %CI: 1.167, 1.910; p=0.001). Meta-regression models suggested that age and male gender may significantly impact on the risk of VTE associated with HCV-positivity. Results of our metaanalysis suggest that HCV-infected subjects may exhibit an increased risk of VTE. However, further high quality studies are needed to extend and confirm our findings.

Supplementary Material to this article is available online at www.thrombosis-online.com.

Does Hepatitis C Affect the Clinical and Patient-Reported Outcomes of Primary Total Hip Arthroplasty at Midterm Follow-Up?

BACKGROUND

It is estimated that 3%-6% of orthopedic patients, many of whom may undergo lower extremity total joint arthroplasty, are infected with hepatitis C. The purpose of this study was to assess the outcomes of patients with hepatitis C who undergo total hip arthroplasty (THA) in comparison with a matched control cohort in terms of (1) patient-reported outcomes, (2) implant survivorship, and (3) complications.

METHODS

Fifty-four hips in 49 hepatitis C-infected patients who underwent a primary THA between 2002 and 2011 were reviewed. This included 10 women and 39 men who had a mean age of 57 years and a mean 6.5-year follow-up. These patients were matched to 163 THAs (148 patients) who did not have this disease and underwent a THA during the same period. We compared implant survivorship, complication rates, Harris hip scores, and University of California, Los Angeles, activity scores. Radiographs were evaluated for loosening, fracture, malalignment, and osteolysis.

RESULTS

The implant survivorship in the hepatitis C-infected patients and comparison group was 96.2% and 98.7%, respectively. The risk of revision surgery in the hepatitis C cohort was 3-fold higher than the comparison group; however, this difference was not significant (P = .26). The hepatitis C-infected cohort had a higher risk of surgical complications (odds ratio = 6.5; P = .034). There were no differences in postoperative Harris hip scores or University of California, Los Angeles, activity scores between the cohorts.

CONCLUSION

Hepatitis C patients can achieve good implant survivorship and clinical outcomes after THA. However, these patients may be at an increased risk for surgical complications and revision rate.

The impact of hepatitis C virus infection on 90-day outcomes following major orthopaedic surgery: a propensity-matched analysis

INTRODUCTION

The impact of hepatitis C virus (HCV) infection on outcomes following major orthopaedic interventions, such as joint arthroplasty or spine surgery, has not been effectively studied in the past. Most prior studies are impaired by small samples, limited surveillance for adverse events, or the potential for selection bias to confound results. In this context, we sought to evaluate the impact of HCV infection on 90-day outcomes following joint arthroplasty or spine surgery using propensity-matched techniques.

MATERIALS AND METHODS

This study utilized 2006-2014 claims from TRICARE insurance. Adults who received spine surgical procedures, total knee and hip arthroplasty were identified. Covariates included demographic factors, a diagnosis of HCV and medical co-morbidities defined by International Classification of Disease-9th revision (ICD-9) code. Outcomes consisted of 30- and 90-day mortality, complications and readmission. A propensity score was used to balance the cohorts with logistic regression techniques employed to determine the influence of HCV infection on post-operative outcomes.

RESULTS

The propensity-matched cohort consisted of 2262 patients (1131 with and without HCV). Following logistic regression, patients with HCV were found to have increased odds of 30-day complications (OR 1.87; 95% CI 1.33, 2.64; p < 0.001), 90-day complications (OR 1.55; 95% CI 1.16, 2.08; p = 0.003) and 30-day readmission (OR 1.46; 95% CI 1.04, 2.05; p = 0.03).

CONCLUSION

HCV infection was found to increase the risk of complication and readmission following spine surgery and total joint arthroplasty. Patients should be counseled on their increased risk prior to surgery. Health systems that treat a higher percentage of patients with HCV need to consider the increased risk of complications and readmission when negotiating with insurance carriers.

Coinfection with Hepatitis C and HIV Is a Risk Factor for Poor Outcomes After Total Knee Arthroplasty

Background

As medical management continues to improve, orthopaedic surgeons are likely to encounter a greater proportion of patients who have coinfection with human immunodeficiency virus (HIV) and hepatitis-C virus (HCV).

Methods

The New York Statewide Planning and Research Cooperative System (SPARCS) database was used to identify patients undergoing total knee arthroplasty between 2010 and 2014. Patients were stratified into 4 groups on the basis of HCV and HIV status. Differences regarding baseline demographics, length of stay, total charges, discharge disposition, in-hospital complications and mortality, and 90-day hospital readmission were calculated.

Results

Between 2010 and 2014, a total of 137,801 patients underwent total knee arthroplasty. Of those, 99.13% (136,604) of the population were not infected, 0.62% (851) had HCV monoinfection, 0.20% (278) had HIV monoinfection, and 0.05% (68) were coinfected with both HCV and HIV. Coinfected patients were more likely to be younger, female, a member of a minority group, homeless, and insured by Medicare or Medicaid, and to have a history of substance abuse. HCV and HIV coinfection was a significant independent risk factor for increased length of hospital stay (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.75 to 4.81), total hospital charges in the 90th percentile (OR, 2.02; 95% CI, 1.12 to 3.67), ≥2 in-hospital complications (OR, 2.04; 95% CI, 1.04 to 3.97), and 90-day hospital readmission (OR, 3.53; 95% CI, 2.02 to 6.18).

Conclusions

Patients coinfected with both HCV and HIV represent a rare but increasing population of individuals undergoing total knee arthroplasty. Recognition of unique baseline demographics in these patients that may lead to suboptimal outcomes will allow appropriate preoperative management and multidisciplinary coordination to reduce morbidity and mortality while containing costs.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Medical Comorbidities Impact the Episode-of-Care Reimbursements of Total Hip Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) costs are a source of great interest in the currently evolving health care market. The initiation of a bundled payment system has led to further research into costs drivers of this commonly performed procedure. One aspect that has not been well studied is the effect of comorbidities on the reimbursements of THA. The purpose of this study was to determine if common medical comorbidities affect these reimbursements.

METHODS

A retrospective, level of evidence III study was performed using the PearlDiver supercomputer to identify patients who underwent primary THA between 2007 and 2015. Patients were stratified by medical comorbidities and compared using the analysis of variance for reimbursements of the day of surgery, and over the 90-day postoperative period.

RESULTS

A cohort of 250,343 patients was identified. Greatest reimbursements on the day of surgery were found among patients with a history of cirrhosis, morbid obesity, obesity, chronic kidney disease (CKD) and hepatitis C. Patients with cirrhosis, hepatitis C, chronic obstructive pulmonary disease, atrial fibrillation, and CKD incurred in the greatest reimbursements over the 90-day period after surgery.

CONCLUSION

Medical comorbidities significantly impact reimbursements, and inferentially costs, after THA. The most costly comorbidities at 90 days include cirrhosis, hepatitis C, chronic obstructive pulmonary disease, atrial fibrillation, and CKD.

Conversion to total hip arthroplasty after failed proximal femoral nail antirotations or dynamic hip screw fixations for stable intertrochanteric femur fractures: a retrospective study with a minimum follow-up of 3 years

Background

Conversion to total hip arthroplasty (CTHA) is a relatively common procedure after a failed dynamic hip screw (DHS) or proximal femoral nail anti-rotation (PFNA) fixation of intertrochanteric fractures, but there have been far fewer reports specifically describing the long-term results of CTHA after failed treatments of stable intertrochanteric fractures with DHS or PFNA. The aim of the present study was to compare the clinical and radiological outcomes of CTHA after failed PFNA or DHS fixations of stable intertrochanteric fractures after a minimum follow-up of 3 years.

Methods

Between January 2005 and April 2014, we retrospectively reviewed 142 active elderly patients treated at our institution (a single institution study). A total of 72 patients (72 hips; 41 women, 31 men; mean age 76.9 years old; range 60–92 years old) who underwent conversion of a failed PFNA to a THA were compared with 70 patients (70 hips; 36 women, 34 men; mean age 75.0 years old; range 60–90 years old) who underwent CTHA after a failed DHS fixation. The mean follow-up periods were 48 (range 43–52) and 48 (range 44–52) months for the DHS and PFNA groups, respectively. Clinical and radiologic evaluations were performed on all patients. The primary outcome was the Harris Hip Score (HHS). The secondary outcomes were the complication rates.

Results

The Harris Hip Score (HHS) improved from 50.61 ± 3.23 preoperatively to 85.28 ± 4.45 at the last follow-up in the PFNA group and from 51.46 ± 3.90 to 84.50 ± 4.34 in the DHS group, with no significant differences noted between the groups at each follow-up (P > 0.05). However, the complication rate in the converted DHS patients was significantly higher (42.9%) than that in the converted PFNA patients (20.8%; P = 0.003). Thirty-seven PFFs (2.4%) occurred during a mean follow-up of 44.4 months. The incidence of periprosthetic fractures was found to be significantly higher (P = 0.021) for the DHS group (15.7%) than for the PFNA group (4.2%).

Conclusions

CTHA after failed DHS fixations of stable intertrochanteric fractures might be associated with a significantly higher complication rate than CTHA after failed PFNA fixations. Therefore, PFNA patients with stable intertrochanteric fractures may be more suitable for CTHA.

Is Hepatitis C Infection Associated With a Higher Risk of Complications After Total Shoulder Arthroplasty?

BACKGROUND

Despite recent advances in the treatment of hepatitis C, it is estimated that nearly 4 million Americans have a chronic form of the disease. Although research in lower-extremity arthroplasty suggests patients with hepatitis C are at risk for increased complications, including postoperative bleeding, acute postoperative infection, and general medical complications, no similar studies have investigated this question in patients undergoing total shoulder arthroplasty (TSA).

QUESTIONS/PURPOSES

We asked whether there is an increased risk of postoperative complications after TSA among patients who have hepatitis C, and if so, what complications in particular seem more likely to occur in this population?

METHODS

Patients who underwent TSA, including anatomic or reverse TSA, were identified in the PearlDiver database using ICD-9 procedure codes. This is a for-fee insurance patient-records database that contains more than 100 million individual patient records from 2005 to 2012. The Medicare data in the database are the complete 100% Medicare Standard Analytical File indexed to allow for patient tracking with time. Patients with hepatitis C who underwent shoulder arthroplasty then were identified using ICD-9 codes. Patients with hepatitis B coinfection or HIV were excluded. A control cohort of patients without hepatitis C who underwent TSA was created and matched to the study cohort based on age, sex, obesity, and diabetes mellitus. A total of 1466 patients with hepatitis C and 21,502 control patients were included. The two cohorts were statistically similar in terms of sex (53% females in study and control groups), age (nearly ½ of each cohort younger than 65 years), obesity (approximately 17% of each cohort were obese), diabetes (approximately 40% of each cohort had diabetes), and followup of each cohort occurred throughout the length of the database from 2005 to 2012. Postoperative complications were assessed using ICD-9 and Current Procedural Terminology codes and compared between cohorts.

RESULTS

Patients with hepatitis C, when compared with matched control subjects, had greater odds of infection within 3 months (odds ratio [OR], 1.7; 95% CI, 1.1-2.6; p = 0.015), 6 months (OR, 1.7; CI, 1.3-2.4; p = 0.001), and 1 year (OR, 2.1; CI, 1.7-2.7; p < 0.001); revision TSA within 1 year (OR, 1.5; CI, 1.1-2.9; p = 0.008) and 2 years (OR, 1.6; CI, 1.2-2.0; p = 0.001), dislocation within 1 year (OR, 1.6; CI, 1.2-2.2; p < 0.001); postoperative fracture within 1 year (OR, 1.8; CI, 1.2-2.6; p = 0.002); systemic or medical complications within 3 months (OR, 1.3; CI, 1.0-1.6; p = 0.022); and blood transfusion within 3 months (OR, 1.7; CI, 1.4-1.9; p < 0.001).

CONCLUSIONS

Hepatitis C is associated with an increased risk for complications after TSA, including infection, dislocation, fracture, revision TSA, systemic complications, and blood transfusion compared with matched control subjects. Although this study is able to identify increased odds of complications in patients with hepatitis C, the mechanism by which these occur is likely not solely related to the virus, and is more likely related to a higher degree of case complexity in addition to other postoperative socioeconomic factors.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The effect of chronic liver disease on acute outcomes following cervical spine trauma

BACKGROUND CONTEXT

The adverse impact of chronic liver diseases, including chronic hepatitis and cirrhosis, on outcomes following orthopedic surgery has been increasingly recognized in recent years. The impact of these conditions on acute outcomes following spinal trauma remains unknown.

STUDY DESIGN

This is a cohort control study that uses patient records in the Massachusetts Statewide Inpatient Dataset (2003-2010).

PURPOSE

The study aimed to evaluate whether chronic liver disease increased the odds of mortality, complications, failure to rescue (FTR), reoperation, and hospital length of stay (LOS) following cervical spine trauma.

PATIENT SAMPLE

The sample is composed of 10,841 patients with cervical spine trauma.

OUTCOME MEASURES

Posttreatment morbidity, mortality, reoperation, and LOS were the outcome measures.

METHODS

Differences between patients with and without chronic liver disease were evaluated using chi-square or Wilcoxon rank-sum tests. Logistic and negative binomial regression techniques were used to adjust for confounders, including whether a surgical intervention was performed. Receiver operator characteristic curves were used to assess final model discrimination.

RESULTS

There were 117 patients with chronic liver disease identified in the cohort. The rate of surgical intervention for cervical trauma was not significantly different between patients with and without chronic liver disease (odds ratio [OR]: 0.82, 95% confidence interval [CI]: 0.52-1.29). Mortality (OR: 2.12, 95% CI: 1.23-3.66), FTR (OR: 2.86, 95% CI: 1.34-6.11), complications (OR: 1.65, 95% CI: 1.12-2.45), and LOS (regression coefficients: 0.31, 95% CI: 0.14-0.48) were all significantly increased for patients with chronic liver disease in final adjusted models that controlled for differences in case-mix and whether a surgical procedure was performed. Final models explained approximately 72% of the variation in mortality and FTR.

CONCLUSIONS

Our novel findings indicate that patients with chronic liver disease may be at elevated risk of posttreatment morbidity and mortality following cervical spine trauma. Medical comanagement in the acute period following injury and optimization before surgery may diminish the potential for adverse events.

Renal and Gastrointestinal Considerations in Patients Undergoing Elective Orthopaedic Surgery

To minimize perioperative complications after orthopaedic procedures, patients may undergo medical optimization, which includes an assessment of their renal function and gastrointestinal (GI) system. The GI and renal systems are complex, and their proper optimization in the preoperative period can influence the success of any procedure. Several factors can prevent complications and reduce morbidity, mortality, and the cost of care, including a thorough evaluation and screening, with particular emphasis on anemia and its renal and GI causes; management of medications that are metabolized by the liver and excreted by the kidneys; and careful attention to the patient's nutritional status.

Total joint arthroplasty in patients with chronic infectious liver disease

The opportunity for total joint arthroplasty (TJA) in patients with chronic infectious liver disease is rapidly expanding. This is the product of both superior survival of chronic hepatitis patients, evolving implant technologies, and improvement of techniques in TJA. Unfortunately, treating this group of patients is not without significant challenges that can stem from both intrahepatic and extrahepatic clinical manifestations. Moreover, many subclinical changes occur in this cohort that can alter hemostasis, wound healing, and infection risk even in the asymptomatic patient. In this review, we discuss the various clinical presentations of chronic infectious liver disease and summarize the relevant literature involving total joint arthroplasty for this population. Hopefully, through appropriate patient selection and perioperative optimization, treating surgeons should see continued improvement in outcomes for patients with chronic infectious liver disease.