Optimal timing for elective total hip replacement in HIV-positive patients

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.

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.

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.

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 draining surgical wound post total hip and knee arthroplasty: what are my options? A narrative review

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are successful orthopaedic procedures with an ever-increasing demand annually worldwide, and persistent wound drainage (PWD) is a well-known complication following these procedures. Despite many definitions for PWD having been proposed, a validated description remains elusive.

PWD is a risk factor for periprosthetic joint infection (PJI). PJI is a devastating complication of THA and TKA, and a leading cause of revision surgery with dramatic morbidity and mortality and a significant burden on health socioeconomics.

Prevention of PJI has become an essential focus in THA and TKA. Understanding the pathophysiology, risk factors and subsequent management of PWD may aid in decreasing the rate of PJI.

Risk factors of PWD can be divided into modifiable and non-modifiable patient risk factors, pharmacological and surgical risk factors. No gold standard treatment protocol to address PWD exists; however, non-operative options progressing to surgical interventions have been described.

The aim of this study was to review the current literature regarding PWD and consolidate the risk factors and management strategies available.

Cite this article: EFORT Open Rev 2021;6:872-880. DOI: 10.1302/2058-5241.6.200054

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.

Head and neck surgical antibiotic prophylaxis in resource-constrained settings

PURPOSE OF REVIEW

Antimicrobial resistance represents a global threat and causes almost 700 000 deaths per year. The rapid dissemination of resistant bacteria is occurring globally, turning this into the primary threat to public health in the 21st century and forcing organizations around the globe to take urgent action.

RECENT FINDINGS

About risks related to surgical site infection (SSI) in head and neck surgery, surgical limitations in resource-constrained settings, comorbidities and the risk of SSI, evidence about surgical prophylaxis from low and middle-income countries, SSI gap between the developed and developing worlds and how to reduce resistance.

SUMMARY

Antibiotic protocols can be adjusted to local and regional bacterial resistance profiles, taking into account the availability of antibiotics and cost limitations on each country in order to decrease the SSI risk.

Reducing Surgical Site Infections During Otolaryngology Surgical Missions

OBJECTIVES

To determine what measures an otolaryngology-head and neck surgery team might adopt to decrease the incidence of surgical site infection (SSI) on a short-term surgical mission. Despite concerns about safety and efficacy, short-term surgical missions remain the predominant structure for humanitarian surgical care in low- and middle-income countries (LMIC). Hospitals in high-income countries strive to improve surgical outcomes through implementation of World Health Organization (WHO) safe surgery guidelines. Reduction of SSI risk is a key part of this effort.

METHODS

Literature review and practical experience.

RESULTS

WHO recommendations for reducing SSI are based largely on research done in the North America and Europe. LMIC populations are younger; comorbidities are fewer; infectious disease and trauma are prevalent; and delays in access to care are common. SSI are much more frequent in resource-limited settings. Recommendations regarding preoperative assessment, operating room environment, instrument sterilization, surgical antibiotic prophylaxis, surgical site preparation, gloving, draping, and postsurgical care are reviewed in the context of a surgical mission at a typical LMIC government hospital.

CONCLUSION

Many of the WHO guidelines on reduction of SSI are logical and applicable to the short-term surgical missions; others may need to be modified. Careful prospective data collection and clinical trials are needed to learn which interventions are valid and which should be changed.

LEVEL OF EVIDENCE

5 Laryngoscope, 130:1388-1395, 2020.