Total Hip Arthroplasty in Human Immunodeficiency Virus-Positive Patients: A Concise Follow-Up at 10 to 14 Years

Total hip and knee arthroplasty in HIV- and HCV-positive hemophilia patients: short term follow-up of 14 patients

BACKGROUND

Haemophilic arthropathy (HA) is a common comorbidity of haemophilia. Some people with haemophilia (PWH) were human immunodeficiency virus (HIV)-positive. Arthroplasty is an effective treatment for end-stage HA. This study was carried out to report the effectiveness and satisfaction following total hip arthroplasty (THA) or total knee arthroplasty (TKA) in PWH with HIV.

PATIENTS AND METHODS

All patients with haemophilia and HIV undergoing THA or TKA in our centre from January 2015 to June 2020 were reviewed. All patients were followed for at least twenty-four months. The improvements in postoperative indicators were evaluated at the latest follow-up, including the Visual Analogue Scale (VAS) score, range of motion (ROM), and validated joint scores such as Knee Society Score (KSS; clinical and functional) and Harris Hip Score (HHS). The complications and satisfaction were analysed likewise. Those were utilized to weigh the risks and benefits of the procedure in the population.

RESULTS

Fourteen patients (7 hips and 14 knees) were included in the study. The follow-up of the THA cohort was 53.3 months (range, 27-82) and the TKA cohort was 50.1 months (range, 25-85), respectively. The average VAS score was ameliorated from 7.3 to 3.0 and 6.6 to 2.8 in the two groups (P < .001, respectively). Similarly, two cohorts (THA and TKA) showed statistically significant changes in the extension and flexion ROM between the preoperative and the latest follow-up (P < .05, P < .001, respectively). Besides, statistically significant differences between the preoperative and final follow-up values of HHS (from 41.6 to 82.3), clinical KSS (from 34.8 to 72.8), and functional KSS (from 42.9 to 73.2) were observed (P < .001, respectively). Notably, there were 4 complications noted among 21 arthroplasties performed, giving a 19.0% complication rate. Based on the satisfaction score, the majority of patients were optimistic about the arthroplasty.

CONCLUSION

Given these findings, THA or TKA of the PWH with HIV is a worthwhile procedure and can be performed by an experienced and collaborative multidisciplinary team in a tertiary centre with a good haemophilia care system.

Periprosthetic Joint Infection Diagnosis: A Narrative Review

Replacement of native joints aims to restore patients' quality of life by relieving pain and improving joint function. While periprosthetic joint infection (PJI) affects a small percentage of patients, with an estimated incidence of 1-9% following primary total joint replacement, this postoperative complication necessitates a lengthy hospitalisation, extended antibiotic treatment and further surgery. It is highlighted that establishing the correct diagnosis of periprosthetic infections is critical in order for clinicians to avoid unnecessary treatments in patients with aseptic failure. Of note, the PJI diagnosis could not purely rely upon clinical manifestations given the fact that heterogeneity in host factors (e.g., age and comorbidities), variability in infection period, difference in anatomical location of the involved joint and discrepancies in pathogenicity/virulence of the causative organisms may confound the clinical picture. Furthermore, intra-operative contamination is considered to be the main culprit that can result in early or delayed infection, with the hematogenous spread being the most prevalent mode. To elaborate, early and hematogenous infections often start suddenly, whereas chronic late infections are induced by less virulent bacteria and tend to manifest in a more quiescent manner. Last but not least, viruses and fungal microorganisms exert a role in PJI pathogenesis.

Midterm Results of Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Human Immunodeficiency Virus-Infected Patients in South Korea

Background

Studies have reported that osteonecrosis of the femoral head (ONFH) is more prevalent in patients with human immunodeficiency virus (HIV). Total hip arthroplasty (THA) is considered reasonable management of ONFH. However, only scarce data exist on the outcomes of THA for HIV-infected patients in South Korea. The purpose of this study was to evaluate the midterm results of HIV-positive patients who underwent THA for ONFH.

Methods

We performed a retrospective review of HIV-infected patients with ONFH who underwent THA in our institution from 2005 to 2021. Twenty-two hips in 15 patients underwent THAs with cementless implants. The clinical and radiographic evaluation was performed at each follow-up, and any complication was recorded.

Results

The mean follow-up period was 5.2 years (range, 1.0-16.0 years). The mean age of the HIV infected patients with osteonecrosis at the time of surgery was 44.7 ± 11.6 years. ONFH occurred 9.8 ± 3.7 years after the initial diagnosis of HIV infection. The average modified Harris hip score improved from 58.3 ± 14.8 to 95.2 ± 11.3 at the latest follow-up. Surgical complications such as infection, nerve injury, or dislocation were not present. The radiographic evidence of stable fixation by bone ingrowth without migration was seen in all implants.

Conclusions

Our data suggest that THA is a safe and valid option of treatment for ONFH in well-controlled HIV-infected patients in Korea. Further large-scale nationwide studies are warranted.

Joint replacement and human immunodeficiency virus

The incidence of human immunodeficiency virus (HIV)-infected cases that need total joint replacement (TJR) is generally rising. On the other hand, modern management of HIV-infected cases has enabled them to achieve longevity while increasing the need for arthroplasty procedures due to the augmented dege-nerative joint disease and fragility fractures, and the risk of osteonecrosis. Although initial investigations on joint replacement in HIV-infected cases showed a high risk of complications, the recent ones reported acceptable outcomes. It is a matter of debate whether HIV-infected cases are at advanced risk for adverse TJR consequences; however, the weak immune profile has been associated with an increased probability of complications. Likewise, surgeons and physicians should be aware of the complication rate after TJR in HIV-infected cases and include an honest discussion of the probable unwelcoming complication with their patients contemplating TJR. Therefore, a fundamental review and understanding of the interaction of HIV and arthroplasty are critical.

Complications of primary total hip arthroplasty in human immunodeficiency virus-positive patients with femoral head osteonecrosis

BACKGROUND

Femoral head osteonecrosis (FHON) is a well-recognised complication in patients with human immunodeficiency virus (HIV) infection. Total hip arthroplasty (THA) is a reliable solution to FHON and has provided functional improvement and pain relief in these patients. Higher complication rates, in particular infections, have been reported in the series of THAs done in the HIV-positive patients. The purpose of this study was to evaluate the complication rate of THA for FHON in HIV-positive patients managed with the highly active antiretroviral therapy (HAART) protocols.

METHODS

A retrospective review was performed of HIV-positive patients with FHON who underwent THAs over a 10-year period at a single institution.

RESULTS

A total of 56 THAs (44 patients) met the inclusion criteria. The mean age at the time of THAs was 47 (range 34-60) years. Of the 44 patients, 39 (88.6%) were males. The mean follow-up was 6.6 (range 2.0-11.3) years. The overall complication rate was 12.5%, with 2 (3.6%) cases of deep periprosthetic infections.

CONCLUSIONS

HIV-positive patients with FHON undergoing THAs do have a considerable complication rate (12.5%). The deep periprosthetic infection rate (3.6%) in these patients, however, has decreased with contemporary disease modification protocols.

Joint Replacement Surgeries Can Be Safely Performed in HIV Patients

Whether joint replacement surgery can be performed safely on HIV patients is still a matter of debate. This study aimed to report the surgical efficacy and complications of joint replacement surgery in HIV patients. A total of 21 HIV patients and 27 non-HIV patients who underwent arthroplasties in our hospital were retrospectively reviewed. The 21 HIV patients received 29 joint replacement surgeries including 27 cases of total hip arthroplasty (THA) and 2 cases of total knee arthroplasty (TKA). The non-HIV patients received 16 THA, 10 TKA, and 3 unicompartmental arthroplasty (UKA). The length of hospital stay of HIV patients was significantly lower than that of non-HIV patients. At the last follow-up, there were no significant complications both in the HIV group and the non-HIV groups. No medical staff had any occupational exposure. We concluded that joint replacement surgery in HIV patients is safe and effective. Optimization of patients is key to treatment success. Strictly following the standardized protection protocol can prevent the risk of occupational exposure.

Incidence of complications and revision surgery in HAART compliant HIV patients undergoing primary total hip and knee arthroplasty: an institutional review

INTRODUCTION

Human immunodeficiency virus (HIV) positive patients are at high risk for osteonecrosis along with age-related osteoarthritis, resulting in a high number of joint reconstruction surgeries at younger ages in these immunosuppressed patients. Few previous studies have reported on patient outcomes in HAART (highly active antiretroviral therapy) compliant patients undergoing primary arthroplasty. The aim of this study is to report one institution's overall rate of complications and revision in HAART-compliant patients after primary hip and knee arthroplasty.

METHODS

A retrospective chart review was performed spanning a 4 year period. This study included 50 primary joint arthroplasty patients diagnosed with HIV including 13 TKA (total knee arthroplasty) and 37 THA (total hip arthroplasty) with a prior diagnosis of HIV infection. Preoperative CD4 count and viral loads were recorded. Charts were reviewed for post-operative complications including infection and revision.

RESULTS

The were a total of 11 postoperative complications (22%). There were 3 cases (6%) of soft tissue infection, 3 cases (6%) of implant loosening, 2 cases (4%) of dislocation, 1 case (2%) of lower extremity weakness, 1 case (2%) of venous thrombosis, and 1 case (2%) of arthrofibrosis. Of all patients, there were 6 cases of revision in this cohort (12%), 5 of which were aseptic etiology. All 3 infected patients had a history of IVDU. Two of these infected patients resolved with IV antibiotics while 1 underwent two-stage revision (2%). Patients that experienced post-operative complications had significantly elevated preoperative CD4 levels (983 versus 598, p = 0.003).

CONCLUSION

Arthroplasty is a viable option for HAART-compliant patients. Most previous studies showing a higher risk for deep tissue infection and revision in HIV patients have not accounted for modern HAART. Our results show that compliance with HAART has vastly improved the outcomes of arthroplasty in these patients, while a history of IVDU is likely the largest risk factor for infection in this population.

Outcomes of revision arthroplasty for hip joint infection in matched groups of HIV-positive and HIV-negative patients

BACKGROUND

Several studies reported on periprosthetic infection after primary THA in HIV-positive patients, but very few showed the results of its revision.

OBJECTIVE

The aim was to compare primary and secondary clinical outcomes after revision arthroplasty for hip joint infection in matched groups of HIV-infected and HIV-negative patients.

METHODS

Using the hospital database, thirteen HIV-positive patients (13 infected hips) and thirteen HIV-negative patients of the matched control group (13 infected hips) were identified and their records were studied retrospectively. They underwent revision surgery aimed at infection arrest and total hip replacement due to infection developed after primary THA or infected spacers. Harris Hip Score, reinfection rate, limb shortening, and definite outcomes were evaluated with Wilcoxon, Mann-Whitney, and Chi-squared tests.

RESULTS AND DISCUSSION

Spacers with antibiotics were implanted in patients of both groups at the first step of revision, except one HIV-infected patient who had resection arthroplasty. The mean follow-up was 29.4±2.7 and 33.±2.9 months for the HIV-group and control group, respectively. Three patients of the HIV-group completed two-stage revision arthroplasty versus ten patients from the control group. Re-infection rate was higher in the HIV-group. At final follow-ups, the mean HHS was significantly different (53±3.2 points in the HIV-group versus 79.14±3.1 points in the control group) along with limb length discrepancy (3.71±0.43 versus 1.4±0.32).

CONCLUSION

Both primary and secondary clinical outcomes of revision arthroplasty for hip joint infection in HIV-positive patients were significantly worse than in the matched group of HIV-negative patients. Revisions in HIV-positive group resulted in a higher reinfection rate, a small number of definite two-stage revisions, and lower functional scores.

Total knee arthroplasty in patients with haemophilic arthropathy is effective and safe according to the outcomes at a mid-term follow-up

BACKGROUND

Haemophilic arthropathy (HA), a common complication of haemophilia, is secondary to recurrent joint bleeding and increases the prevalence of end-stage osteoarthritis (OA). Total knee arthroplasty (TKA) is a reliable treatment for haemophilia patients. This study was performed to evaluate the mid-term outcomes of TKA for end-stage HA. We hypothesized that the rate of complications of TKA is higher for patients with haemophilia than for patients without haemophilia.

METHODS

Patients with HA undergoing TKA from January 2015 to December 2016 in our centre were retrospectively reviewed. All patients were managed by a multidisciplinary team. The improvements in flexion contracture, range of motion (ROM), Knee Society Score (KSS; clinical and functional), Visual Analogue Scale (VAS) score, and satisfaction at final follow-up were analysed to evaluate the effectiveness of TKA in HA. The complications were analysed to evaluate the safety of TKA in HA.

RESULTS

Twenty-eight patients (32 knees) were included in the study. The follow-up was 69.1 ± 5.1 months. Significant differences between the preoperative and final follow-up values of flexion contracture (which changed from 21.1 ± 6.5° to 14.3 ± 4.1°, P < 0.001), ROM (from 53.9 ± 15.0° to 70.3 ± 16.3°, P < 0.001), clinical KSS (from 33.5 ± 14.4° to 62.7 ± 9.5°, P < 0.001), functional KSS (from 46.1 ± 15.5° to 62.9 ± 9.7°, P < 0.001), and VAS score (from 6.8 ± 1.4 to 4.9 ± 1.3, P < 0.01) were observed. Importantly, the incidence of complications was 15.6% and the satisfaction was 100% in our mid-term study.

CONCLUSION

Under elaborative and comprehensive management, TKA is effective and safe in patients with advanced HA on the basis of mid-term follow-up outcomes.

Rotator cuff repair in HIV-positive patients ages 65 and older: only slight increase in risk of general postoperative surgical complications

PURPOSE

To examine postoperative complications associated with rotator cuff repair (RCR) in HIV-positive patients ages 65 and older.

METHODS

Data were collected from the Medicare Standardized Analytic Files between 2005 and 2015 using the PearlDiver Patient Records Database. Subjects were selected using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Demographics including age, sex, medical comorbidities, and smoking status were collected. Complications were examined at 7-day, 30-day, and 90-day postoperative time points. Data were examined with univariate and multivariate analyses.

RESULTS

The study included 152,114 patients who underwent RCR, with 24,486 (16.1%) patients who were HIV-positive. Following univariate analysis, patients with HIV were observed to be more likely to develop 7-day, 30-day, and 90-day postoperative complications. However, the absolute risk of each complication was quite low for HIV-positive patients. Univariate and multivariate analysis showed that within 7 days following surgery, patients with HIV were more likely to develop myocardial infarction (OR 2.5, AR 0.1%) and sepsis (OR 2.5, AR 0.04%). Within 30 days, HIV-positive patients were at increased risk for postoperative anemia (OR 2.8, AR 0.1%), blood transfusion (OR 3.3, AR 0.1%), heart failure (OR 2.3, AR 0.8%), and sepsis (OR 2.7, AR 0.1%). Within 90 days, mechanical complications (OR 2.1, AR 0.1%) were increased in the HIV-positive group.

CONCLUSION

Postoperative complications of RCR occurred at increased rates in the HIV-positive group compared to the HIV-negative group in patients ages 65 and older. In particular, increased risk for myocardial infarction, sepsis, heart failure, anemia, and mechanical complications was noted in HIV-positive patients. However, the actual percentage of patients who experienced each complication was low, indicating RCR is likely safe to perform even in older HIV-positive patients. As more older adults living with HIV present for elective orthopedic procedures, the results of the present study may reassure physicians who are considering RCR as an option for patients in this particular population, while also informing providers about potential complications.

LEVEL OF EVIDENCE

III.

HIV-Positive Patients Are at Increased Risk of Venous Thromboembolism After Total Joint Replacement

BACKGROUND

Antiretroviral therapy has improved the life expectancy of HIV patients, leading to an increase in total joint replacement for age-related osteoarthritis. HIV patients are inherently hypercoagulable at baseline. The goal of our study was to compare the incidence of venous thromboembolism (VTE) in HIV patients with HIV-negative controls after total joint replacement.

METHODS

A multicenter, retrospective cohort study of 110 HIV patients (85 hips and 25 knees) and 240 HIV-negative controls (180 hips and 85 knees) between 2000 and 2018. Prophylactic anticoagulation was used in 98% of patients postoperatively-low-molecular weight heparin (73%), warfarin (19%), aspirin (6%), and clopidogrel (1%).

RESULTS

The VTE rate was 3.6% in the HIV-positive group (2.5% total hip arthroplasty [THA] and 8.0% total knee arthroplasty [TKA]) and 0.4% in the control group (0% THA and 1.7% TKA). VTEs occurred at the median (interquartile range) time of 40 days (1 to 52) post-op in the HIV group and 3 days post-op in the one control. Multivariable logistic regression adjusting for sex, smoking, history of VTE, and joint replaced identified HIV as an independent predictor of VTE (odds ratio 10.9, 95% confidence interval 1.1 to 114.0, P = 0.046). All patients with VTE were treated with warfarin (5 to 9 months); two cases were complicated by hemarthrosis and excessive bleeding at the insulin injection site.

CONCLUSION

We observed increased rates of symptomatic VTE in HIV patients after THA (2.5%) and TKA (8%) compared with HIV-negative control patients (0% and 1.7%, respectively). HIV positivity was identified as an independent predictor of perioperative VTE. Our data suggests that HIV patients may be at higher risk for post-op VTE than HIV-negative patients. Surgeons may want to consider the use of more potent anticoagulation (ie, warfarin or novel anticoagulants) for a longer duration in HIV-positive patients. However, further studies are necessary to form evidence-based guidelines regarding this practice.

LEVEL OF EVIDENCE

Level III, prognostic.

Human immunodeficiency virus in total hip arthroplasty

Human immunodeficiency virus (HIV) is a pandemic affecting more than 35 million people worldwide. The aim of this review is to describe the association between HIV and total hip arthroplasty (THA) and assess patient risk factors to optimize functional outcomes and decrease rates of revision.

Since the advent of highly active antiretroviral treatment (HAART), HIV-infected patients are living longer, which allows them to develop degenerative joint conditions. HIV and HAART act independently to increase the demand for THA. HIV-positive patients are also more predisposed to developing avascular necrosis (AVN) of the hip and femoral neck fractures due to decreased bone mineral density (BMD).

Prior to the widespread implementation of access to HAART in homogenous cohorts of HIV-infected patients undergoing THA, reports indicated increased rates of complications. However, current literature describes equivocal functional outcomes and survival rates after THA in HIV-positive patients controlled on HAART when compared to HIV-negative controls.

HIV-infected patients eligible for THA should be assessed for medical co-morbidities and serum markers of disease control should be optimized.

Periprosthetic joint infection (PJI) is a leading cause of revision THA, and HIV is a modifiable risk factor. Importantly, the significance is negated once patients are placed on HAART and achieve viral suppression.

THA should not be withheld in HIV-infected patients injudiciously. However, HIV is a burgeoning epidemic and all patients should be identified and started on HAART to avoid preventable peri-operative complications.

Cite this article: EFORT Open Rev 2020;5:164-171. DOI: 10.1302/2058-5241.5.190030