Good Functional Outcomes and Low Infection Rates in Total Hip Arthroplasty in HIV-Positive Patients, Provided There Is Strict Compliance With Highly Active Antiretroviral Therapy

Surgical management of appendicitis in patients with human immunodeficiency virus (HIV) positivity: a propensity score-matched analysis in a base hospital for HIV treatment in Japan

PURPOSE

To investigate the impact of human immunodeficiency virus (HIV) infection on surgical outcomes after appendectomy.

METHODS

Data on patients who underwent appendectomy for acute appendicitis between 2010 and 2020 at our hospital were investigated retrospectively. The patients were classified into HIV-positive and HIV-negative groups using propensity score-matching (PSM) analysis, adjusting for the five reported risk factors for postoperative complications: age, sex, Blumberg's sign, C-reactive protein level, and white blood cell count. We compared the postoperative outcomes of the two groups. HIV infection parameters, including the number and proportion of CD4 + lymphocytes and the HIV-RNA levels were also compared before and after appendectomy in the HIV-positive patients.

RESULTS

Among 636 patients enrolled, 42 were HIV-positive and 594 were HIV-negative. Postoperative complications occurred in five HIV-positive patients and eight HIV-negative patients, with no significant difference in the incidence (p = 0.405) or severity of any complication (p = 0.655) between the groups. HIV infection was well-controlled preoperatively using antiretroviral therapy (83.3%). There was no deterioration in parameters and no changes in the postoperative treatment in any of the HIV-positive patients.

CONCLUSION

Advances in antiviral drugs have made appendectomy a safe and feasible procedure for HIV-positive patients, with similar postoperative complication risks to HIV-negative patients.

Analysis of inpatient complications in HIV/AIDS patients undergoing total hip arthroplasty - A propensity matched cohort study

Patients with human immunodeficiency virus (HIV) are at higher risk for orthopedic related diseases due to dysregulation in bone metabolism and metabolic effects related to their medication regimen. Furthermore, the rate of hip arthroplasty in HIV patients is increasing. With the recent changes in THA methodologies and improvements in HIV treatment, there is a need for updated research analyzing hip arthroplasty outcomes in this high-risk patient population. In this study, we used a national database to evaluate postoperative outcomes in HIV patients undergoing THA compared to THA patients without HIV. We use a propensity algorithm to create a cohort of 493 HIV negative patients for matched analysis. Among the 367,894 THA patients included in this study, 367,390 patients were HIV negative and 504 were HIV positive. The HIV cohort had a lower mean age (53.34 vs 65.88, p < 0.001), lower proportion of females (44% vs 76.4%, p < 0.001), lower incidence of diabetes without complications (5% vs 11.1%, p < 0.001) and a lower incidence of obesity (0.544 vs 0.875, p = 0.002). In the unmatched analysis, the incidence of acute kidney injury (4.8% vs 2.5%, p = 0.004), pneumonia (1.2% vs 0.2%, p = 0.002), periprosthetic infection (3.6% vs 1%, p < 0.001), and wound dehiscence (0.6% vs 0.1%, p = 0.009) were higher in HIV cohort, most likely due to inherent demographic variances present in the HIV population. In the matched analysis, the rates of blood transfusion (5.0% vs 8.3%, p = 0.041) were lower in the HIV cohort. Other post-operative variables, such as rates of pneumonia, wound dehiscence, and surgical site infections were not statistically significant between the HIV positive population and HIV negative matched cohort. Our study found similar rates of postoperative complications in HIV positive and HIV negative patients. The rate of blood transfusions in HIV positive patients was also noted to be lower. Our data suggests that THA is a safe procedure in patients infected with HIV.

Outcomes following cholecystectomy in human immunodeficiency virus-positive patients treated with antiretroviral therapy: A retrospective cohort study

The number of the human immunodeficiency virus (HIV)-positive patients are increasing worldwide, and more HIV-positive patients are undergoing urgent or elective cholecystectomy. There is still insufficient evidence on the relationship between surgical complications of cholecystectomy and antiviral status in HIV-positive patients. The purpose of the present study is to evaluate surgical outcomes after cholecystectomy in HIV-positive patients. Records of consecutive HIV-positive patients who underwent cholecystectomy between January 2010 and December 2020 were reviewed retrospectively. Patients were divided into urgent and elective surgery groups. Urgent surgery was defined as surgery within 48 hours of admission. Postoperative complications were evaluated according to the Clavien-Dindo classification. A total of 30 HIV-positive patients underwent urgent (n = 7) or elective (n = 23) cholecystectomy. Four complications (13.3%) occurred, and the rate was significantly higher in the urgent group than in the elective group (p = 0.008). However, all complications were minor (3 cases of grade I and one case of grade II), and there were no severe postoperative complications. There was no significant difference in CD4+ lymphocyte status in all patients and between the 2 groups before and after surgery (p = 0.133). No cases of postoperative deterioration in the control of HIV infection were observed. In conclusion, cholecystectomy in HIV-positive patients with controlled HIV under recent antiretroviral therapy may be performed safely even in an emergency situation.

Movement is Life-Optimizing Patient Access to Total Joint Arthroplasty: HIV and Hepatitis C Disparities

This article is one of a series focusing on how the preoperative optimization process, if designed for underserved communities, can improve access to care and reduce disparities. In this article, we specifically focus on methods to improve optimization for patients with HIV and hepatitis C to facilitate their access to total joint arthroplasty. 1.2 million Americans are currently living with HIV (people living with HIV). African Americans and Hispanics account for the largest proportion of new HIV diagnoses and make up the highest proportion of people living with HIV. HIV-positive patients, many of them with complex comorbidities, are at a high risk for postoperative complications. Optimization of this vulnerable cohort involves a multidisciplinary strategy focusing on optimizing treatment modalities to reduce viral loads, leading to lower complication rates and a safer environment for the surgical team. The rates of hepatitis C have been increasing in the United States, and more than half of individuals living with hepatitis C are unaware that they are infected. Hepatitis C infections are highest in African Americans, and the rates of chronic hepatitis C are highest in those born outside the United States. Patients with hepatitis C have an increased risk for surgical complications after total joint arthroplasty, and studies have demonstrated that these risks normalize when patients are preoperatively screened and treated. Optimization in these vulnerable groups includes working closely with psychosocial resources, the primary care team, and infectious disease specialists to ensure treatment access and compliance.

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.

Has modern human immunodeficiency virus therapy decreased complications following total knee arthroplasty?

BACKGROUND

Anti-retroviral therapy (ART) remains the cornerstone of decreasing morbidity and mortality in human immunodeficiency virus (HIV) patients. However, a large study comparing HIV patients taking ART prior to total knee arthroplasty (TKA) is lacking. We sought to examine: (1) readmissions; (2) post-operative complications; and (3) revisions in ART-treated or untreated HIV patients compared with a non-HIV population.

METHODS

We queried a national, all-payer database to identify TKA patients from 2010-2020 (n = 1,393,357). The presence or absence of ART was identified and matched with non-HIV patients based on age, sex, diabetes, obesity, and tobacco status resulting in 889 patients in each cohort. Readmissions, post-operative complications, and revisions were assessed.

RESULTS

Readmissions were higher among all HIV patients and even higher in those not taking ART, as compared to the matching cohort (4.8 versus 1.6%, p < 0.01). Prosthetic joint infections (PJIs) at 1-year were higher among HIV patients who were either taking ART (4.0%; OR, 1.41 [0.82-2.45]) or not taking ART (5.1%; OR, 2.44 [1.42-4.21]) as compared to non-HIV patients (2.1%, all p < 0.03). Revision rates at 1-year trended higher in HIV patients who were taking ART (2.6%; Odds Ratio (OR), 1.94 [0.96-3.93]) and who did not take ART (3.1%; OR, 2.38 [1.20-4.70]), compared to non-HIV patients (1.3%, all p < 0.09).

CONCLUSIONS

ART-treated HIV patients are associated with lower readmissions, post-operative complications, and revisions when compared to HIV patients not taking ART. The findings of this study underscore the utility of ART and patient optimization to reduce risk in HIV patients.

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.

The Effect of Modern Antiretroviral Therapy on Complication Rates After Total Hip Arthroplasty

Background:

Antiretroviral therapy (ART) remains the cornerstone of decreasing morbidity and mortality in patients with human immunodeficiency virus (HIV), but additional information on its impact on total hip arthroplasty (THA) complication rates is needed to mitigate risks postoperatively. Therefore, we sought to examine patients with HIV who were and were not taking ART compared with a cohort without HIV in the setting of primary THA with respect to the following outcomes: length of stay, readmissions, and postoperative infection.

Methods:

A retrospective database review was performed with PearlDiver for patients who underwent THA from 2010 to 2019 (n = 729,101). Patients with HIV who were and were not taking ART were then identified and were matched with patients without HIV at a 1:1:1 ratio based on age, sex, Charlson Comorbidity Index, diabetes, obesity, and tobacco use, resulting in 601 patients in each cohort. Length of stay, 30-day readmissions, and complications at 90 days and 1 year were analyzed. Continuous outcomes were measured via Student t tests, and categorical outcomes were measured via chi-square analyses.

Results:

Patients with HIV who were and were not taking ART were found to have similar lengths of stay compared with patients without HIV (range, 4.1 to 4.3 days). Readmission rates were slightly higher in patients with HIV who were taking ART at 4.2% (odds ratio [OR], 1.96 [95% confidence interval (CI), 0.99 to 3.87]) and patients with HIV who were not taking ART at 3.5% (OR, 1.63 [95% CI, 0.81 to 3.30]) compared with patients without HIV at 2.1%. Periprosthetic joint infection rates at 1 year were slightly higher among patients with HIV who were not taking ART at 5.3% (OR, 1.41 [95% CI, 0.82 to 2.45]) compared with patients with HIV who were taking ART at 4.2% (OR, 1.09 [95% CI, 0.61 to 1.94]) and patients without HIV at 3.8%.

Conclusions:

Patients with HIV who are and are not taking ART are approaching normalization to the general population in the setting of THA. It is important to note that, although complications may have been mitigated by modern therapy, extreme care should be taken while clinically evaluating these patients prior to the surgical procedure given the complexity of their clinical status. The findings of this study underscore the utility of ART and patient optimization to reduce risk in this patient population.

Level of Evidence:

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