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Successful Treatment of HCV Prior to TKA Improves Outcomes

Key findings

  • In this retrospective study of 127 hepatitis C virus (HCV)-infected patients who underwent total knee arthroplasty (TKA), 64 patients who achieved sustained virologic response prior to surgery were compared with the 63 who did not receive antiviral treatment
  • Untreated patients were 12 times more likely to undergo revision TKA, three times more likely to develop a prosthetic joint infection and three times more likely to have a sur­gical complication than patients who were cured of HCV
  • Of the seven patients in whom antiviral treatment had failed, 43% had a surgical com­plication
  • Elective TKA should be delayed for HCV-infected patients until after a course of treatment with a second-generation direct-acting antiviral

Past studies have shown that infection with the hepatitis C virus (HCV) predisposes patients to poor outcomes after total hip arthroplasty. Manifestations of the infection include diabetes, metabolic syndrome, thrombocytopenia and, in patients co-infected with HIV, bone-related complications, which may influence the physiological response to surgery and interfere with wound healing.

Oral direct-acting antiviral agents (DAAs) essentially cure HCV, with typical rates of sustained virologic response at >95%. In a retrospective study, Harry S. Bedair, MD, orthopedic surgeon at the Center for Hip & Knee Replacement at Massachusetts General Hospital, and colleagues found that patients who were cured of HCV infection prior to total knee arthroplasty (TKA) had fewer postoperative complications. The results are reported in The Bone & Joint Journal.

Study Subjects

The researchers studied 127 HCV-infected patients who underwent primary TKA between November 2011 and April 2018 at two tertiary care centers. 64 patients were treated for HCV prior to surgery and achieved sustained virologic response (HCV RNA level <15 IU/mL within 24 weeks after completing treatment).

The other 63 patients did not receive anti-HCV treatment before TKA. The cured and untreated groups had equivalent demographic and comorbidity profiles. The average follow-up was 28 months for cured patients and 20 months for treated patients.

Postoperative Outcomes

On multivariable analysis, untreated patients had:

  • A significantly higher risk of surgical complications compared with cured patients (OR, 3.1; P = .04)
  • A significantly higher risk of needing revi­sion TKA (OR, 11.5; P = .02)
  • A nonsignificantly higher risk of prosthetic joint infection (OR, 3.3; P = .09)

There were six infections in the untreated group (8.5%) compared with one in the cured group (1.4%) that required two-stage revision TKA. Four untreated patients (6%) developed superficial cellulitis. One untreated patient with a history of HCV cirrhosis and chronic heart failure died from septic shock one-week postop­eratively. Two cured patients required above-knee amputation due to sepsis following failed irrigation and debridement.

Comparison of Treatment Types

Of the cured patients, 60% had been treated with DAAs, 31% had been treated with interferon-based regimens and for 9% the type of treatment was unknown. There were no significant differences between the DAA and interferon groups with respect to the risk of medical or surgical compli­cations.

Unsuccessful HCV Treatment

Seven patients had a course of HCV treatment that failed. Six of these patients had received interferon therapy; for the other, the type of treatment was unknown. At an average follow-up of 34 months, three patients (43%) had a surgical com­plication, further supporting the idea that successful HCV treatment reduces complications.

Rethinking Cost Containment

When DAAs were introduced, their high cost prompted payers to restrict access to HCV-infected patients with more advanced liver disease. This approach fails to prevent transmission of the disease. Moreover, treat­ing HCV before a patient develops advanced disease might decrease the risk of hepatic and extrahepatic manifestations.

Second-generation DAAs are cost-effective compared with previous standard-of-care regimens or no treatment. At Mass General, all patients are now screened for HCV before elective TKA. During the study period, surgery was not delayed if patients had not been treated for HCV because some payers did not cover DAAs. Now that those drugs are usually covered, protocols are in place to have HCV treated first.

Learn more about the Center for Hip and Knee Replacement at Mass General

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