Protease inhibitors and avascular necrosis: a systematic review and meta-analysis

Femoral head and acetabular necrosis combined with hip subluxation in people with HIV: a case report and literature review

INTRODUCTION

HIV is widely prevalent in all regions of the world. The use of antiretroviral drugs has dramatically reduced the mortality rate of HIV-related diseases, but correspondingly increased the incidence of chronic complications in HIV-positive people. Related studies have found that the incidence of osteonecrosis of the femoral head is higher in HIV-positive people, but the co-occurrence of femoral head necrosis, acetabular necrosis and hip joint dislocation in HIV-positive patients is rare.

METHODS

We report a 50-year-old man with a 15-month history of progressively worsening right hip pain with movement restriction. According to the CT findings of the other hospital, the patient was admitted to the hospital with femoral head necrosis. After the admission, the relevant X-ray, CT and MRI examinations showed that the right femoral head collapsed and deformed, with the surrounding bone sclerosis, bone fragments, loose body of the joint, right hip subluxation, acetabular marginal osteogeny, and local microcystic degeneration. The left femoral head was in good shape, and cystic degeneration can be seen under the articular surface. The patient was finally diagnosed with femoral head necrosis and acetabular necrosis combined with hip subluxation.

RESULTS

The pain of the patient was significantly relieved after the operation, and the patient was discharged from the hospital one week after the start of treatment to continue rehabilitation training. During the follow-up one month after the operation, the self-reported pain disappeared completely, and the limitation of activity was significantly improved.

Analysis of the efficacy of drilling decompression autologous bone marrow and allogeneic bone grafting in the treatment of HIV-positive patients with early osteonecrosis of the femoral head

OBJECTIVE

To investigate the efficacy of treating patients with HIV-positive osteonecrosis of the femoral head using drilled decompression autologous bone marrow and allogeneic bone grafting.

METHODS

40 patients (44 hips) with early osteonecrosis of the femoral head treated by drilling decompression autologous bone marrow and allogeneic bone grafting since October 2015 were retrospectively analyzed, among which 20 patients (24 hips) were HIV-positive patients with early osteonecrosis of the femoral head, 16 males and 4 females, age 22-43 years, average 39.6 ± 10.18 years, and 20 patients (20 hips) in the same period HIV-negative early osteonecrosis of the femoral head patients, 13 males and 7 females, aged 48-78 years, mean 63.50 ± 7.94 years were negative controls. General information including ARCO stage, Harris score, VAS score, hematological indexes including CD4+ T lymphocyte count, and HIV viral load was recorded for all patients before surgery. All patients were operated on by drilling and decompression of the necrotic area, harvesting autologous iliac bone marrow with allogeneic bone, and bone grafting through the decompression channel. The patients were followed up regularly at 6, 12, and 24 months after surgery and annually thereafter, and the repair of the necrotic femoral head was observed by reviewing the frontal and lateral X-ray, CT or MRI of the hip joint, and the complications and functional recovery of the hip joint was counted and compared between the two groups.

RESULTS

All patients were followed up, and the ARCO stages in the HIV-positive group were stage I 2 hips, stage IIA 6 hips, stage IIB 8 hips, stage IIC 6 hips, and stage III 2 hips, with a follow-up time of 12 to 60 months and a mean of 24.6 months. In the negative control group, there were 3 hips in ARCO stage I, 7 hips in stage IIA, 5 hips in stage IIB, 3 hips in stage IIC, and 2 hips in stage III, and the follow-up time ranged from 13 to 62 months, with an average of 24.8 months. The Harris score and VAS score of the hip in both groups improved significantly at 6 months postoperatively compared with those before surgery (P < 0.001). The difference between the Harris score of the hip in the positive group at 24 months postoperatively compared with that at 6 months postoperatively was statistically significant, but the VAS score at 24 months postoperatively compared with that at 6 months postoperatively was not statistically significant. In the negative group, there was no statistically significant difference in the Harris score and VAS score of the hip at 24 months postoperatively compared with those at 6 months postoperatively. In the positive group, there was a trend of continuous increase in hip BMD from the beginning of the postoperative period (P < 0.001). There was no statistically significant difference between the negative group and the positive group at the 24 months postoperatively follow-up except for the Harris score, which was statistically significant (P < 0.001), and the VAS score, which was statistically insignificant. At the 24 months postoperatively follow-up, patients in both groups had good recovery of hip function, and no complications such as vascular and nerve injury and fracture occurred during the perioperative period and follow-up period, and no complications related to incisional infection and pulmonary infection occurred during hospitalization.

CONCLUSION

The treatment of early HIV-positive osteonecrosis of the femoral head patients with autologous bone marrow and allogeneic bone grafting by drilling and decompression to remove the tissue in the necrotic area of the femoral head can effectively stop the process of osteonecrosis of the femoral head and promoting femoral head repair in HIV-positive patients is a safe and effective method for treating HIV-positive patients with early osteonecrosis of the femoral head, and can effectively delay or postpone total hip replacement in 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.

Antiretroviral Therapy and Periarticular Osteonecrosis Development in Patients With HIV

INTRODUCTION

With modern antiretroviral therapy (ART), HIV has become a chronic condition. Previous studies have not definitively assessed the risk of periarticular osteonecrosis (ON) that ART poses to the HIV population.

METHODS

A retrospective case-control study using the PearlDiver database was done using International Classification of Diseases codes. Patients were selected from 2010 to 2019 with a diagnosis of periarticular ON and HIV taking ART (HIV+/ART+) and not taking ART (HIV+/ART-). The control was patients HIV- and not on ART. Subcategorization, by International Classification of Diseases codes, was used for which joint was affected-hip, knee, or shoulder-excluding patients with ON of the jaw. Chi-squared univariate analysis was used to compare incidence rates and control for age, sex, Elixhauser comorbidities, and other known risk factors for developing ON in multivariable analysis.

RESULTS

In total, 219,853 patients had HIV between 2010 and 2019. Of those patients, 123,710 (56.27%) had a history of ART (HIV+/ART+), while 96,143 (43.74%) did not (HIV+/ART-). Difference in incidence rates for HIV+/ART+ was higher in any joint (+1.7%), as well as the hip (+1.31%), knee (+0.08%), and shoulder (+0.08%). All risk factors met inclusion criteria in the multivariate analysis except coagulopathy. Multivariate analysis found that patients in the HIV+/ART+ cohort had higher odds of developing periarticular ON when compared with the HIV+/ART- cohort in any joint (odds ratios = 1.40; 95% CI, 1.38 to 1.42), hip (OR:1.41; 95% CI, 1.38-1.43), knee (OR:2.56; 95% CI, 2.39 to 2.74), and shoulder (OR:1.05; 95% CI, 1.01-1.10).

CONCLUSION

Patients with HIV taking ART have well-established morbidity and mortality benefits. However, this study found that ART is associated with a higher risk of developing periarticular ON when compared with those not taking ART. Therefore, clinicians should be hypervigilant of patients on ART and their risk of ON, especially asymptomatic patients, and focus on modifiable risk factors and early surgical correction.

LEVEL OF EVIDENCE

III.

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.

Management of Antiretroviral Therapy with Boosted Protease Inhibitors-Darunavir/Ritonavir or Darunavir/Cobicistat

A major challenge in the management of antiretroviral therapy (ART) is to improve the patient's adherence, reducing the burden caused by the high number of drugs that compose the treatment regimens for human immunodeficiency virus positive (HIV+) patients. Selection of the most appropriate treatment regimen is responsible for therapeutic success and aims to reduce viremia, increase the immune system response capacity, and reduce the incidence rate and intensity of adverse reactions. In general, protease inhibitor (PI) is one of the pillars of regimens, and darunavir (DRV), in particular, is frequently recommended, along with low doses of enzyme inhibitors as cobicistat (COBI) or ritonavir (RTV), by the international guidelines. The potential of clinically significant drug interactions in patients taking COBI or RTV is high due to the potent inhibitory effect on cytochrome CYP 450, which attracts significant changes in the pharmacokinetics of PIs. Regardless of the patient or type of virus, the combined regimens of DRV/COBI or DRV/RTV are available to clinicians, proving their effectiveness, with a major impact on HIV mortality/morbidity. This study presents current information on the pharmacokinetics, pharmacology, drug interactions, and adverse reactions of DRV; it not only compares the bioavailability, pharmacokinetic parameters, immunological and virological responses, but also the efficacy, advantages, and therapeutic disadvantages of DRV/COBI or DRV/RTV combinations.

Osteonecrosis of the Femoral Head in Korean Patients with Human Immunodeficiency Virus Infection

Background

Osteonecrosis of the femoral head (ONFH) is a disabling condition that often necessitates total hip arthroplasty (THA). Although ONFH occurs more frequently among patients with human immunodeficiency virus (HIV) than among the general population, there is little epidemiological information regarding ONFH in Korean patients with HIV. In the present study, we aimed to investigate the incidence and clinical features of ONFH among Korean patients with HIV.

Materials and Methods

In this retrospective study, we reviewed the medical records of 1,250 Korean patients with HIV treated from January 1990 to December 2019. A standardised data collection sheet was used to obtain clinical information. Imaging data were analysed by a radiologist in accordance with the 2019 revised version of the Association Research Circulation Osseous (ARCO) staging system for ONFH.

Results

Among the 1,250 included patients, 13 patients (1.04%; 3 women, 10 men) were diagnosed with ONFH. The overall incidence of ONFH was 1.29 per 1,000 person-years (PYs) (95% confidence interval [CI]: 0.7 – 2.4 per 1,000 PYs). Median age among the 13 patients with ONFH was 47 years (interquartile range [IQR]: 41 – 57 years). The median duration since HIV diagnosis was 4.8 years (IQR: 2.3 – 10.1 years). The median CD4 cell count at the time of ONFH diagnosis was 381 cells/ mm³ (IQR: 161 – 551 cells/mm³). At the initial diagnosis of ONFH, 83.3% of patients exhibited bilateral involvement. ARCO stage 3 or 4 osteonecrosis was observed in 83% of patients. Among 22 hips, stage 1 ONFH was noted in 2 (9.1%), stage 2 ONFH was noted in 7 (31.8%), stage 3 ONFH was noted in 9 (40.9%), and stage 4 ONFH was noted in 4 (18.2%). THA was eventually performed in 84.6% of patients. Five (38.5%) patients had a history of steroid use, 4 (30.8%) patients had a history of alcohol abuse and 10 (76.9%) were smokers. Eight (61.5%) patients had a history of acquired immune deficiency syndrome-defining illness, including 7 with tuberculosis and 1 with pneumocystis pneumonia. Nine patients (69.2%) had a nadir CD4 cell count <200/µL, and 3 (23.1%) had a history of bone fracture. Overall, 84% of patients were exposed to antiretroviral therapy, while 54% had taken protease inhibitors for more than 1 year.

Conclusion

Considering that relatively high incidence of ONFH in patients with HIV, a high index of suspicion for those with risk factors and those with groin or hip pain for is required in HIV-infected patients.

Avascular Necrosis of Both Hips From Iatrogenic Cushing 's Syndrome due to Coadministration of Fluticasone and Ritonavir in an HIV-Infected Patient

We report a case of avascular necrosis (AVN), hypercalcemia, and iatrogenic Cushing’s syndrome in an HIV-positive patient taking inhaled (ICS) and nasal corticosteroids fluticasone and ritonavir.

A 45-year-old HIV-infected African-American woman was seen for initial evaluation for multinodular goiter in December 2015. Relevant medications were ritonavir, raltegravir, darunavir, fluticasone propionate HFA, and nasal fluticasone propionate. Physical examination revealed classical cushingoid appearance but laboratory testing showed abnormal adrenocorticotropic hormone (ACTH) stimulation test. A diagnosis of iatrogenic Cushing’s syndrome due to inhibition of fluticasone metabolism from protease inhibitor (PI) therapy with secondary adrenal suppression was made. Fluticasone nasal spray and HFA were discontinued and hydrocortisone replacement dose was initiated. The patient’s Cushing’s related symptoms improved over several months. Follow-up evaluation showed non-parathyroid hormone-mediated hypercalcemia. A detailed laboratory evaluation looking for the etiology for hypercalcemia was unremarkable except for an elevated urine N-telopeptide/creatinine ratio. Meanwhile, the patient developed a new symptom of hip pain. MRI of both hips showed bilateral AVN. Sickle cell screen was negative and a right hip replacement was completed in May 2017.

Since this is the fourth case report of AVN from iatrogenic Cushing’s syndrome in an HIV-infected patient taking a PI and ICS concomitantly, there is more likely a causal relationship and not simply a coincidental finding. Extreme caution should be used when considering any ICS therapy in combination with PIs in HIV-infected patients.

Electrocuted Hip: Late Consequences of Electrical Shock Injuries of Orthopaedic Relevance: A Case Report and Review of Literature

CASE

A 43-year-old man suffered household electric shock from 220 V alternating current when he accidently touched a live wire with his left hand. Subsequently, he was diagnosed to have osteonecrosis of the left femoral head and underwent total hip arthroplasty.

CONCLUSION

We suggest that the electric current could have thrombosed the terminal subsynovial vessels of the femoral head, leading to osteonecrosis. To the best of authors' knowledge, only 2 cases of osteonecrosis of the hip after electric shock have been reported in the literature. A literature review of the delayed consequences of electric shock injuries pertaining to orthopaedics is also presented.

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

Total shoulder arthroplasty in patients with HIV infection: complications, comorbidities, and trends

BACKGROUND

Patients with human immunodeficiency virus (HIV) infection were previously at substantial risk for immunosuppression-related complications. As a result of highly active antiretroviral therapy, HIV-infected patients are living longer and are presenting for elective surgery. Outcomes in HIV-infected patients are well described for hip and knee arthroplasty but not for total shoulder arthroplasty (TSA). The purpose of this study was to examine postoperative complications of TSA in HIV-positive patients.

METHODS

We queried the entire 2005 to 2012 Medicare database. Current Procedural Terminology and International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify the procedure, demographics, comorbidities, and postoperative complications. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

The query returned 2528 HIV-positive patients who underwent TSA or reverse TSA (RTSA). There was increased utilization of TSA and RTSA in this population from 2005 to 2012; 1353 patients had 2-year follow-up. These patients were slightly older and had higher prevalence of comorbidities, suggesting a sicker cohort. HIV-positive patients had alarmingly higher rates of 90-day cerebrovascular accident (OR, 35.98; CI, 30.34-42.67). HIV-positive patients had higher overall rates of broken prosthetic joints (OR, 1.72; CI, 1.20-2.47), periprosthetic infection (OR, 1.36; CI, 1.01-1.82), and TSA revision or repair (OR, 2.44; CI, 1.81-3.28).

CONCLUSIONS

To our knowledge, this is the first study that directly examines the postoperative outcomes of HIV-positive patients after TSA or RTSA. As more of these patients present for surgery, surgeons should be aware that these patients might be at increased risk for certain postoperative surgical and medical complications.

Early Outcomes of Primary Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Patients with Human Immunodeficiency Virus in China

Background:

Studies have reported that patients with human immunodeficiency virus (HIV) have a high incidence of osteonecrosis of the femoral head (ONFH). Total hip arthroplasty (THA) is an effective management of ONFH. However, little data exist regarding the use of THA for the HIV patients with ONFH in China. This study reviewed the outcomes of HIV-positive patients who underwent THA for ONFH, compared with HIV-negative individuals.

Methods:

The patients who underwent THA for ONFH from September 2012 to September 2014 in Beijing Ditan Hospital, Capital Medical University were retrospectively studied. Twenty-eight HIV-positive patients and 35 HIV-negative patients underwent 48 THAs and 45 THAs with cementless components, respectively. Medical records and follow-up data were reviewed. Harris Hip Score (HHS) was applied to evaluate the pain and function of the hips before and after THA. Complications such as wound healing, surgical site infection, deep venous thrombosis, pulmonary embolism, sepsis, mortality, and complications from the prosthesis were reviewed. The operation time, blood loss, and hospital stay were compared between the two groups.

Results:

The mean follow-up period was 19.5 ± 5.8 months (ranging from 6 to 30 months). The mean age of the HIV-positive patients with osteonecrosis at the time of surgery was 35 years old, which was significantly lower than that of the HIV-negative group (42 years old) (P < 0.05). The HIV-positive patients underwent surgery a mean of 2.5 years after their original symptoms, which was significantly shorter than the HIV-negatives’ (mean 4 years) (P < 0.05). Among HIV-positive patients, the prevalence of being male and rate of bilateral procedures were significantly higher than those in the HIV-negative group (P < 0.05). The operation time in HIV-positive patients was significantly longer than that in HIV-negative patients (P < 0.05). There were no significant differences in blood loss or hospital stay between the two groups (P > 0.05). The HHSs of two groups significantly improved after THAs (P < 0.05), without significant difference between two groups. No wound complication, sepsis, mortality, prosthesis complication, and occupational exposure occurred, except for two cases of heterotopic ossification and one case of humeral head necrosis.

Conclusions:

ONFH is more likely to occur bilaterally in younger HIV-positive males. The development of osteonecrosis seems faster in HIV-positive patients than in HIV-negative patients. This should be cautionary for asymptomatic HIV-positive patients with low viral RNA level and in the primary HIV stage. Despite longer operation times in the HIV-positive patients than in the HIV-negative patients, THA is still a safe and efficient approach to treat ONFH in HIV-positive patients. The incidence of complications is much lower than previously reported. However, the long-term follow-up is needed.