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Antiretroviral Therapy and Periarticular Osteonecrosis Development in Patients With HIV. J Am Acad Orthop Surg 2023; 31:e148-e156. [PMID: 36656276 DOI: 10.5435/jaaos-d-22-00619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/18/2022] [Indexed: 01/20/2023] Open
Abstract
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.
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Munhoz Lima ALL, Oliveira PR, Carvalho VC, Godoy-Santos AL, Ejnisman L, Oliveira CR, Uip DE, Duarte MIS. Osteonecrosis of the femoral head in people living with HIV: anatomopathological description and p24 antigen test. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2018; 10:83-90. [PMID: 29872352 PMCID: PMC5975606 DOI: 10.2147/hiv.s162305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective To examine the presence of HIV in bone tissue of people living with HIV (PLWHIV) with osteonecrosis of femoral head and describe clinical and anatomopathological findings. Design This is a case series which included 44 PLWHIV with osteonecrosis of femoral head who underwent total hip arthroplasty. Methods Clinical data were obtained through analysis of the patients’ medical records. Bone tissue obtained during total hip arthroplasty was retrieved and sent for conventional and immunohistochemical analysis. Monoclonal antibodies were used to mark the p24 (HIV), CD31 (vascular endothelial cells), CD68 (macrophages), and D240 (cells of the lymphatic endothelium) antigens. Results Dyslipidemia was found in 48% of the patients and lipodystrophy in 31%. Histological analysis showed similar characteristics for the entire sample. Degeneration of joint cartilage was visualized with the presence of fissures and fibrillations, as well as subchondral sclerosis and necrosis of the subchondral cancellous bone tissue. Lymphoplasmocytic inflammatory reaction was observed, with the presence of macrophages containing a foamy, vacuolated cytoplasm, as well as the presence of ceroid pigment and occasional granulation tissue. The reaction with the monoclonal anti-p24 antibody was negative in the samples from all 44 PLWHIV undergoing hip arthroplasty. Reactions with the anti-CD31 and anti-D240 antibodies were negative. Staining with CD68 antibody confirmed that the cells visualized with foamy, vacuolated cytoplasm were macrophages. Conclusion p24 HIV antigen was not detected in the bone tissue of PLWHIV and osteonecrosis. The most frequent anatomopathological findings were extensive necrosis of bone tissue, large vacuoles filled with fat cells, inflammatory lymphoplasmocytic reaction with macrophages containing vacuolated cytoplasm, and the presence of ceroid pigment.
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Affiliation(s)
- Ana Lucia L Munhoz Lima
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Priscila Rosalba Oliveira
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Vladimir C Carvalho
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Alexandre Leme Godoy-Santos
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Leandro Ejnisman
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Claudia R Oliveira
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - David E Uip
- Faculdade de Medicina da Fundacao do ABC, São Paulo, Brazil
| | - Maria Irma S Duarte
- Departamento de Patologia, Faculdade de Medicina FMUSP, Universidade de São Paulo, Sao Paulo, Brazil
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Bayard C, Ledergerber B, Flepp M, Lecompte T, Moulin E, Hoffmann M, Weber R, Staehelin C, Di Benedetto C, Fux CA, Tarr PE, Hasse B. Associations Between Antiretroviral Treatment and Avascular Bone Necrosis: The Swiss HIV Cohort Study. Open Forum Infect Dis 2017; 4:ofx177. [PMID: 29026869 PMCID: PMC5632527 DOI: 10.1093/ofid/ofx177] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 08/12/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND HIV-infected individuals have an increased risk of avascular bone necrosis (AVN). Antiretroviral therapy (ART) and particularly protease inhibitors (PI) have been implicated as a risk factor. We aimed to study the associations of ART with the occurrence of AVN among Swiss HIV Cohort Study participants (SHCS). METHODS We used incidence density sampling to perform a case control study within the Swiss HIV Cohort Study (SHCS) comparing prospectively collected AVN cases and controls by conditional logistic regression analysis. To evaluate the effect of ART, multivariable models were adjusted for HIV transmission risk group, age, alcohol consumption, use of corticosteroids, CD4 nadir, maximum viral load, and pancreatitis. RESULTS We compared 74 AVN cases and 145 controls. Associations with AVN were shown for heterosexual HIV acquisition (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.1-10), alcohol consumption (OR, 2.7; 95% CI, 1.3-5.7), and hyperlipidemia (OR, 3.6; 95% CI, 1.4-9.6). After adding ART substances to the multivariable base model, there was evidence of an association for treatment with tenofovir (TDF) >1 year (OR, 4.4; 95% CI, 1.4-14) with AVN. Neither exposure to specific frequently prescribed ART combinations or ART drug classes nor cumulative ART exposure showed any associations with AVN. CONCLUSIONS In the HIV-infected population, a combination of risk factors such as heterosexual HIV acquisition, moderate to severe alcohol intake, and hyperlipidemia seem to contribute to AVN. ART does not seem to be a relevant risk factor for AVN. The association of prolonged TDF exposure with AVN needs to be confirmed.
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Affiliation(s)
- Cornelia Bayard
- Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Bruno Ledergerber
- Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Markus Flepp
- Center for Infectious Diseases Zurich, Zurich, Switzerland
| | - Thanh Lecompte
- Division of Infectious Diseases, University Hospital Geneva, Geneva, Switzerland
| | - Estelle Moulin
- Department of Medicine, Internal Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Matthias Hoffmann
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital, St. Gallen, Switzerland
| | - Rainer Weber
- Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Cornelia Staehelin
- Division of Infectious Diseases and Hospital Epidemiology, University and Inselspital Berne, Berne, Switzerland
| | | | - Christoph A Fux
- Department of Infectious Diseases and Hospital Hygiene, Kantonsspital Aarau, Aarau, Switzerland
| | - Philip E Tarr
- Division of Infectious Diseases and Hospital Epidemiology, Kantonsspital Baselland Bruderholz, University of Basel, Bruderholz, Switzerland
| | - Barbara Hasse
- Division of Infectious Diseases and Hospital Epidemiology, University of Zurich, University Hospital Zurich, Zurich, Switzerland
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Borges ÁH, Hoy J, Florence E, Sedlacek D, Stellbrink HJ, Uzdaviniene V, Tomazic J, Gargalianos-Kakolyris P, Schmid P, Orkin C, Pedersen C, Leen C, Pradier C, Mulcahy F, Ridolfo AL, Staub T, Maltez F, Weber R, Flamholc L, Kyselyova G, Lundgren JD, Mocroft A. Antiretrovirals, Fractures, and Osteonecrosis in a Large International HIV Cohort. Clin Infect Dis 2017; 64:1413-1421. [DOI: 10.1093/cid/cix167] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/15/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- Álvaro H. Borges
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, and
- Institute for Clinical Medicine, University of Copenhagen, Denmark
| | - Jennifer Hoy
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, Australia
| | | | | | - Hans-Jürgen Stellbrink
- Infektionsmedizinisches Centrum Hamburg (ICH) Study Center, Innere Medizin, Hamburg, Germany
| | - Vilma Uzdaviniene
- Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Janez Tomazic
- University Medical Centre Ljubljana, Clinic of Infectious Diseases Ljubljana, Medical Faculty, University of Ljubljana, Slovenia
| | | | - Patrick Schmid
- Division of Infectious Diseases, Cantonal Hospital St. Gallen, Switzerland
| | - Chloe Orkin
- Barts and The Royal London Hospital NHS Trust, London, United Kingdom
| | | | | | | | | | | | | | | | | | | | | | - Jens D Lundgren
- Centre of Excellence for Health, Immunity and Infections (CHIP), Department of Infectious Diseases, Rigshospitalet, and
| | - Amanda Mocroft
- Department of Infection and Population Health, University College London, UK
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Mehsen-Cêtre N, Cazanave C. Osteoarticular manifestations associated with HIV infection. Joint Bone Spine 2016; 84:29-33. [PMID: 27238195 DOI: 10.1016/j.jbspin.2016.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 11/16/2022]
Abstract
About 150,000 people are HIV-positive in France, and the number of new cases is estimated at 7000-8000 per year, with no tendency to diminish over time. Admissions of HIV-positive patients have been decreasing, in contrast, since 2008, reflecting the dramatic improvements in quality of life and survival provided by triple antiretroviral regimens. HIV infection is now a chronic disease that exposes patients to the virus and antiretroviral drugs for many years. One consequence has been the emergence of new health conditions in HIV-positive patients, such as tumors, cardiovascular disease, and osteoarticular complications. These epidemiological and clinical changes have made it necessary for rheumatologists to learn about the osteoarticular abnormalities associated with the HIV, which they are likely to encounter at some point during their everyday practice. Osteoporosis is one such abnormality, and this review article starts with a discussion of the literature on this topic. Bone loss is common, chiefly in males. Multiple factors are involved. Studies have demonstrated an increase in the fracture risk and, consequently, recommendations about the screening and treatment of osteoporosis have been issued. The focus of this review article then turns to the other rheumatic manifestations seen in HIV-positive patients, including osteomalacia, avascular necrosis, and inflammatory joint disease. Osteoarticular pain is frequently reported by HIV-positive patients. Identifying the cause is essential to determine the best treatment strategy. Interestingly, immunosuppressant drugs, and even biotherapies, have shown a good safety profile in these immunodeficient patients.
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Affiliation(s)
- Nadia Mehsen-Cêtre
- Service de rhumatologie, CHU de Bordeaux, place Amelie-Raba-Léon, 33076 Bordeaux, France.
| | - Charles Cazanave
- USC EA3671, Infections humaines à mycoplasmes et à chlamydiae, University Bordeaux, 33076 Bordeaux, France; USC EA3671, Infections humaines à mycoplasmes et à chlamydiae, INRA, 33000 Bordeaux, France; Service des maladies infectieuses et tropicales, CHU de Bordeaux, 33076 Bordeaux, France
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Permpalung N, Ungprasert P, Summachiwakij S, Leeaphorn N, Knight EL. Protease inhibitors and avascular necrosis: a systematic review and meta-analysis. Int J Antimicrob Agents 2014; 44:93-5. [PMID: 24726526 DOI: 10.1016/j.ijantimicag.2014.02.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 02/14/2014] [Indexed: 02/06/2023]
Abstract
Avascular necrosis (AVN) is a pathological process associated with many medical conditions, including human immunodeficiency virus (HIV) infection. Whether or not the use of protease inhibitors (PIs) confers additional risk for AVN to HIV-infected patients is controversial. Previous epidemiological studies showed an increased risk of AVN among PI users, but these studies did not have enough power to achieve statistical significance. A meta-analysis of case-control studies reporting the odds ratios (ORs) of AVN among HIV-infected patients who were exposed to PIs compared with non-exposed patients was conducted. Pooled ORs and 95% confidence intervals (CIs) were calculated using a fixed-effect Mantel-Haenszel analysis. Four case-control studies were identified and included for data analysis. The meta-analysis demonstrated an increased odds of AVN in participants exposed to PIs, with an OR of 2.09 (95% CI 1.01-4.31; P=0.05). The statistical heterogeneity of this meta-analysis was determined not to be important, with an I(2) of 0%. The meta-analysis revealed a statistically significant increased odds of AVN among PI-exposed, HIV-infected patients. Physician should be aware of this association as it may help guide potential therapeutic options, particularly for patients with other classic risk factors for AVN.
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Affiliation(s)
- Nitipong Permpalung
- Department of Internal Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY 13326, USA
| | - Patompong Ungprasert
- Department of Medicine, Faculty of Medicine, Siriraj Hospital, Bangkok 10700, Thailand.
| | - Sarawut Summachiwakij
- Department of Internal Medicine, Queens Hospital Center, Jamaica, New York, NY 11432, USA
| | - Napat Leeaphorn
- Department of Internal Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY 13326, USA
| | - Eric L Knight
- Department of Internal Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY 13326, USA
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Kerr E, Middleton A, Churchill D, Walker-Bone K. A case-control study of elective hip surgery among HIV-infected patients: exposure to systemic glucocorticoids significantly increases the risk. HIV Med 2014; 15:182-8. [PMID: 24025108 PMCID: PMC5362063 DOI: 10.1111/hiv.12084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This was a cross-sectional study with a nested case-control analysis among a cohort of HIV-infected adults aiming to explore the prevalence of and risk factors for elective hip surgery (total hip arthroplasty and resurfacing). METHODS Cases were identified from the out-patient database of HIV-infected adults attending one tertiary hospital service. For each case, five controls from the same database matched by age, gender and ethnicity were identified. From the case notes, information about demographic factors, HIV factors and risk factors for hip surgery attributable to osteoarthritis or avascular necrosis (body mass index, lipids, alcohol, comorbidities and treatment with oral glucocorticoids) was extracted. RESULTS Among the cohort of 1900 HIV-infected out-patients, 13 cases (12 male) who had undergone hip surgery [0.7%; 95% confidence interval (CI) 0.3-1.1%] were identified, with a median age of 47 years. Eleven of the 13 cases (85%) were Caucasian and seven of the 13 were in stage 3 of HIV infection. Fewer of the cases were in the asymptomatic stage of infection compared with controls [odds ratio (OR) for stage 2 or 3 infection 4.0; 95% CI 0.8-18.5]. Ever having used oral glucocorticoids was highly significantly associated with elective hip surgery (OR 44.6; 95% CI 5.7-347.7). CONCLUSIONS Among this young cohort, the prevalence of elective hip surgery was 0.7%, with the median age at surgery being 47 years. Ever having been exposed to systemic glucocorticoids was highly significantly associated with elective hip surgery, suggesting that the principal mechanism underlying the need for surgery was avascular necrosis. There may be an increased need for elective hip surgery associated with HIV infection.
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Affiliation(s)
- Elizabeth Kerr
- Department of HIV/GU Medicine, Royal Sussex County Hospital, Brighton, BN2 5BE
| | - Annie Middleton
- Department of HIV/GU Medicine, Royal Sussex County Hospital, Brighton, BN2 5BE
| | - Duncan Churchill
- Department of HIV/GU Medicine, Royal Sussex County Hospital, Brighton, BN2 5BE
| | - Karen Walker-Bone
- Brighton & Sussex Medical School, University of Sussex, Falmer, Brighton, East Sussex, BN1 9PX, UK
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Kocjančič B, Moličnik A, Antolič V, Mavčič B, Kralj-Iglič V, Vengust R. Unfavorable hip stress distribution after Legg-Calvé-Perthes syndrome: a 25-year follow-up of 135 hips. J Orthop Res 2014; 32:8-16. [PMID: 24038236 DOI: 10.1002/jor.22479] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 08/08/2013] [Indexed: 02/04/2023]
Abstract
To study the effect of hip and pelvis geometry on development of the hip after Perthes disease, we determined the resultant hip force and contact hip stress distribution in a population of 135 adult hips of patients who had been treated for Perthes disease in childhood. Contra-lateral hips with no record of disease were taken as the control population. Biomechanical parameters were determined by mathematical models for resultant hip force in one-legged stance and for contact hip stress, which use as an input the geometrical parameters assessed from anteroposterior radiographs. The mathematical model for stress was upgraded to account for the deviation of the femoral head shape from spherical. No differences were found in resultant hip force and in peak contact hip stress between the hips that were in childhood subject to Perthes disease and the control population, but a considerable (148%) and significant (p < 0.001) difference was found in the contact hip stress gradient index, expressing an unfavorable, steep decrease of contact stress at the lateral acetabular rim. This finding indicates an increased risk of early coxarthritis in hips subject to Perthes disease.
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Affiliation(s)
- Boštjan Kocjančič
- Department of Orthopaedic Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Whitlock GG, Herbert S, Copas A, Gilson R, Ainsworth JG. Avascular necrosis in HIV patients: a case-control study. Int J STD AIDS 2013; 24:799-803. [PMID: 23970592 DOI: 10.1177/0956462413482814] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study investigates the association of avascular necrosis (AVN) in human immunodeficiency virus (HIV)-positive individuals with possible risk factors, including antiretroviral therapy. Clinic records of all AVN cases diagnosed up to July 2009 in HIV-positive patients attending North Middlesex Hospital, London, UK were retrospectively reviewed. For each case, one control was randomly selected, matched for gender, age, nadir CD4 count and date of HIV diagnosis. Of 15 symptomatic AVN cases identified, eight were in women. Univariate analysis demonstrated significant associations between AVN and a history of systemic steroid use (p = 0.004) and cumulative exposure to protease inhibitor (p = 0.03). Physicians should be aware of the risk of AVN with steroid use, the importance of early diagnosis and avoidance of other risk factors in order to prevent further joint involvement if possible.
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Affiliation(s)
- G G Whitlock
- Centre for Sexual Health & HIV Research, Research Department of Infection and Population Health, University College London, London, UK
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Lin CA, Kuo AC, Takemoto S. Comorbidities and perioperative complications in HIV-positive patients undergoing primary total hip and knee arthroplasty. J Bone Joint Surg Am 2013; 95:1028-36. [PMID: 23780541 DOI: 10.2106/jbjs.l.00269] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Highly active antiretroviral therapy has prolonged the lifespan of individuals infected with human immunodeficiency virus (HIV). We hypothesized that the number of primary total joint arthroplasties performed in this population has been increasing and that HIV infection is not an independent risk factor for postoperative complications. METHODS The Nationwide Inpatient Sample for the years 2000 through 2008 was queried to identify patients who underwent primary total joint arthroplasty. HIV, comorbidities, and complications were identified with use of ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes. Data were analyzed with use of multivariate logistic regression, the Pearson chi-square test, and the Mann-Kendall trend test. RESULTS Of the estimated 5,681,024 admissions for primary total hip and knee arthroplasty in the United States during this period, 8229 (0.14%) were in patients who had HIV. Compared with HIV-negative patients (controls), infected patients were more likely to be younger, be male, and have a history of osteonecrosis, liver disease, drug use, and coagulopathy. The number of total hip and total knee arthroplasties in HIV-positive patients increased from 2000 to 2008 (p < 0.05). Seventy-nine percent (6499) of the total joint arthroplasties in the HIV-positive patients involved the hip. Compared with HIV-negative patients undergoing total hip arthroplasty, HIV-positive patients were more likely to develop acute renal failure (1.3% compared with 0.8%, p = 0.04), develop a wound infection (0.6% compared with 0.3%, p = 0.02), and undergo postoperative irrigation and debridement (0.2% compared with 0.1%, p = 0.01). They were less likely to have a myocardial infarction (0.4% compared with 0.9%, p = 0.04). There was no difference in total complications (8.3% compared with 7.8%, p = 0.52). Similarly, there was no difference in total complications in patients undergoing total knee arthroplasty (7.8% compared with 8.0%, p = 0.76). HIV was not an independent risk factor for complications in total hip arthroplasty (odds ratio [OR], 1.18; 95% confidence interval [CI], 0.95 to 1.47) or total knee arthroplasty (OR, 0.78; 95% CI, 0.49 to 1.25). CONCLUSIONS The incidence of primary total joint arthroplasty in HIV-positive patients has been increasing. These patients were at slightly higher risk of certain immediate postoperative complications because of a higher rate of medical comorbidities. HIV infection was not an independent risk factor for the total rate of perioperative complications. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Carol A Lin
- Department of Orthopaedic Surgery, University of California San Francisco, 500 Parnassus Avenue, MUW 320, San Francisco, CA 94143, USA
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Aseptic osteonecrosis: a newly diagnosed complication in HIV-infected patients undergoing liver transplantation. Transplantation 2012; 94:e20-1. [PMID: 22872296 DOI: 10.1097/tp.0b013e31825fc0d2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Cotter AG, Powderly WG. Endocrine complications of human immunodeficiency virus infection: hypogonadism, bone disease and tenofovir-related toxicity. Best Pract Res Clin Endocrinol Metab 2011; 25:501-15. [PMID: 21663843 DOI: 10.1016/j.beem.2010.11.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Treatment with highly active antiretroviral therapy (HAART) has revolutionized care of patients with HIV infection. The cost of increased survival has been antiretroviral toxicity and increasing age-related co-morbidities that include significant metabolic issues. Hypogonadism was first described in the setting of advanced AIDS and can be primary or secondary. Data regarding treatment largely concern patients with wasting. Varied syndromes involving bone have been described in patients with HIV including osteonecrosis, low bone mineral density (BMD) and osteoporosis, and rarely osteomalacia. Low BMD leading to osteoporosis is the most common bone pathology and may be as a result of HIV infection, drug toxicity or co-morbidities. However, increasingly fragility fractures are reported in HIV-infected patients, suggesting bone demineralization in this population is of clinical relevance. Further research is required to understand its pathogenesis and determine effective management; however, initiation of antiretroviral therapy seems to accelerate (in the short-term) bone demineralization. One particular antiretroviral agent, tenofovir is widely used and is potentially implicated as having a greater role in long-term bone and renal dysfunction. As this population ages, screening for low BMD will become increasingly more important.
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Affiliation(s)
- Aoife G Cotter
- School of Medicine and Medical Sciences, University College Dublin, Belfield, Dublin, Ireland.
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Lamas JL, Ocampo A, Martínez-Vázquez C, Miralles C, Longueira R, Arias M, Sopeña B, Rivera A, Portela D. Osteonecrosis asintomática de la cadera en los pacientes infectados por el virus de inmunodeficiencia humana. Enferm Infecc Microbiol Clin 2010; 28:150-5. [DOI: 10.1016/j.eimc.2009.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Revised: 05/23/2009] [Accepted: 06/15/2009] [Indexed: 11/26/2022]
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15
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Eholié SP, Ouiminga M, Ehui E, Nzunetu G, Ouattara SI, Konan AV, Anglaret X, Bissagnéné E. Avascular osteonecrosis of the femoral head in three West African HIV-infected adults with heterozygous sickle cell disease. Antivir Ther 2010; 14:1011-4. [PMID: 19918106 DOI: 10.3851/imp1398] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Three men (aged 33, 44 and 45 years, CD4(+) T-cell nadir 86 cells/mm(3), 99 cells/mm(3) and 12 cells/mm(3), respectively) were admitted to the Department of Infectious Diseases (Treichville Hospital, Abidjan, Côte d'Ivoire) for hip pain and impaired mobility. Their last available CD4(+) T-cell counts were 243 cells/mm(3), 245 cells/mm(3) and 8 cells/mm(3), respectively. They had all received antiretroviral therapy for >4 years, including lopinavir/ritonavir for >8 months. The other risk factors were hypertriglyceridaemia (n=3), smoking addiction (n=2), alcohol consumption (n=2) and lipodystrophy (n=1). All three patients had heterozygous haemoglobin AS sickle cell disease (percentage of haemoglobin S 41%, 45% and 50%, respectively). The diagnosis of avascular osteonecrosis of the femoral head (unilateral n=2 and bilateral n=1) was documented by CT scan. Only one patient underwent surgical arthroplasty. In resource-limited settings, avascular osteonecrosis is uneasy to diagnose and unlikely to be appropriately treated. Physicians should be aware of its symptoms and risk factors, including HIV infection and antiretroviral therapy. Future studies should explore whether these risk factors might include haemoglobin AS sickle cell disease, a common trait in the West African general population.
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Affiliation(s)
- Serge P Eholié
- Service des Maladies Infectieuses et Tropicales, CHU de Treichville, Abidjan, Côte d'Ivoire.
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Osteonecrosis of the femoral head in patients with type 1 human immunodeficiency virus infection: clinical analysis and review. Clin Rheumatol 2009; 28:815-23. [DOI: 10.1007/s10067-009-1156-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Revised: 02/16/2009] [Accepted: 02/25/2009] [Indexed: 02/06/2023]
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Vallecillo Sánchez G, Güerri Fernández R, Villar García J, Knobel Freud H. Riesgo de necrosis avascular en pacientes con infección por el virus de la inmunodeficiencia humana. Med Clin (Barc) 2008; 131:117-8. [DOI: 10.1157/13124018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Walker UA, Tyndall A, Daikeler T. Rheumatic conditions in human immunodeficiency virus infection. Rheumatology (Oxford) 2008; 47:952-9. [PMID: 18413346 DOI: 10.1093/rheumatology/ken132] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Many rheumatic diseases have been observed in HIV-infected persons. We, therefore, conducted a comprehensive literature search in order to review the prevalence, presentation and pathogenesis of rheumatic manifestations in HIV-infected subjects. Articular conditions (arthralgia, arthritis and SpAs) are either caused by the HIV infection itself, triggered by adaptive changes in the immune system, or secondary to microbial infections. Muscular symptoms may result from rhabdomyolysis, myositis or from side-effects of highly active anti-retroviral therapy (HAART). Osseous complications include osteonecrosis, osteoporosis and osteomyelitis. Some conditions such as the diffuse infiltrative lymphocytosis syndrome and sarcoidosis affect multiple organ systems. SLE may be observed but may be difficult to differentiate from HIV infection. Some anti-retroviral agents can precipitate hyperuricaemia and are associated with arthralgia. When indicated, immunosuppressants and even anti-TNF-alpha agents can be used in the carefully monitored HIV patient. Thus, rheumatic diseases and asymptomatic immune phenomena remain prevalent in HIV-infected persons even after the widespread implementation of highly active anti-retroviral therapy.
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Affiliation(s)
- U A Walker
- Department of Rheumatology, Basel University, Basel, Switzerland.
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de Larrañaga G, Bottaro E, Martinuzzo M, Figueroa R, Iglesias Varela ML, Perés Wingeyer S, Forastiero R, Adamczuk Y, Corti M, Puga L, Benetucci J. Thrombophilia in human immunodeficiency virus-infected patients with osteonecrosis: Is there a real connection? The first case-control study. Clin Appl Thromb Hemost 2007; 15:340-7. [PMID: 18160564 DOI: 10.1177/1076029607310217] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Several reports have described an increased incidence of osteonecrosis in human immunodeficiency virus-infected patients (HIV+), but the cause has not been established. The association between thrombophilia and osteonecrosis in HIV+ was studied. A case-control study in HIV+, 19 cases and 38 controls, was designed. Magnetic resonance imaging was made in both groups to confirm or exclude hip osteonecrosis. The extensive tests of thrombophilia were measured, and the clinical data were recorded, nadir of CD4(+) cell count and well-known risk factors for osteonecrosis. Thrombophilia has been frequently found both in patients with and without osteonecrosis (thrombophilia, 68.4% vs 60.5%), but no specific thrombophilia tests were significantly associated with osteonecrosis. A low nadir of CD4(+) (<60 cells/microL) and corticoid use were significantly (P < .05) associated with osteonecrosis. In multivariate analysis, only nadir of CD4(+) <60 cells/microL remained a predictor of osteonecrosis (odds ratio = 7.33; 95% confidence interval, 1.80-29.82, P = .005). Thrombophilia might have a limited role in the development of osteonecrosis in HIV+. Nadir of CD4(+) <60 cells/microL and corticoid use were main factors.
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Affiliation(s)
- Gabriela de Larrañaga
- Hemostasis and Thrombosis Laboratory, Hospital of Infectious Diseases F. J. Muñiz, Buenos Aires, Argentina.
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Morse CG, Mican JM, Jones EC, Joe GO, Rick ME, Formentini E, Kovacs JA. The incidence and natural history of osteonecrosis in HIV-infected adults. Clin Infect Dis 2007; 44:739-48. [PMID: 17278070 DOI: 10.1086/511683] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Accepted: 11/13/2006] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Osteonecrosis is increasingly recognized as a debilitating complication of human immunodeficiency virus (HIV) infection, but the natural history has not been well described. We previously documented a high prevalence (4.4%) of magnetic resonance imaging (MRI)-documented osteonecrosis of the hip in a cohort of 339 asymptomatic HIV-infected patients. The present study was designed to determine the incidence of newly diagnosed osteonecrosis in this cohort and to describe the natural history of osteonecrosis in HIV-infected patients. METHODS Asymptomatic HIV-infected patients with a previous hip MRI negative for osteonecrosis underwent follow-up MRI. Patients with asymptomatic or symptomatic osteonecrosis were enrolled in a natural history study, which included serial MRIs and a physiotherapy follow-up. RESULTS Two hundred thirty-nine patients underwent a second MRI a median of 23 months after the initial MRI. Osteonecrosis of the femoral head was diagnosed in 3 patients (incidence, 0.65 cases per 100 person-years). During the period of January 1999 through April 2006, symptomatic hip osteonecrosis developed in 13 clinic patients (incidence, 0.26 cases per 100 person-years). Among 22 patients enrolled with symptomatic hip osteonecrosis, 18 had bilateral involvement of the femoral heads, and 7 had osteonecrosis involving other bones. Two (11%) of 18 asymptomatic patients and 13 (59%) of 22 symptomatic patients underwent total hip replacement. The percentage of involvement of the weight-bearing surface of the femoral head and the rate of progression to total hip replacement was significantly greater (P<.001) in symptomatic patients than in asymptomatic patients. CONCLUSIONS HIV-infected patients are at approximately 100-fold greater risk of developing osteonecrosis than the general population. Disease progression is slower in asymptomatic patients than in symptomatic patients. Given the high frequency of total hip replacement in symptomatic patients, studies to assess preventive and treatment strategies are essential.
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Affiliation(s)
- Caryn G Morse
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, Maryland 20892-1662, USA.
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Mary-Krause M, Billaud E, Poizot-Martin I, Simon A, Dhiver C, Dupont C, Salmon D, Roudiere L, Costagliola D. Risk factors for osteonecrosis in HIV-infected patients: impact of treatment with combination antiretroviral therapy. AIDS 2006; 20:1627-35. [PMID: 16868444 DOI: 10.1097/01.aids.0000238409.90571.02] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Osteonecrosis was increasingly associated with HIV infection in the 1990s. It is unclear whether its risk increases with the duration of HIV infection, the duration of combination antiretroviral therapy (cART) or both. OBJECTIVE To analyse factors associated with the rate of symptomatic osteonecrosis, particularly the relative impacts of the duration of HIV infection and the duration of cART, using the French Hospital Database on HIV, which comprises a large number of subjects with substantial follow-up. METHODS Poisson regression model was used to identify factors associated with the rate of osteonecrosis among patients enrolled in 1996-2002. RESULTS The study involved 56,393 subjects with a total follow-up of 229,031 person-years. Symptomatic osteonecrosis was diagnosed in 104 subjects with an incidence rate of 4.5/10,000 person-years. Multivariate analysis identified three factors associated with the rate of osteonecrosis: prior AIDS-defining illnesses [adjusted relative rate (RR), 3.1; 95% confidence interval (CI), 2.0-4.9], the CD4 cell nadir [RR, 1.6 (95% CI, 0.9-2.9) for CD4 cell count 50-199 cells/microl; RR, 1.8 (95% CI, 1.0-3.3) for CD4 cell count < 50 cells/microl; both relative to CD4 cell count > or = 200 cells/microl] and exposure to cART. Compared with unexposed patients, the RR of osteonecrosis ranged from 2.6 (95% CI, 1.2-5.9) in patients treated with cART for < 12 months to 5.1 (95% CI, 2.1-12.6) in patients treated for > or = 60 months. CONCLUSIONS Osteonecrosis appears to be a complication of both HIV infection and cART.
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Gutiérrez F, Padilla S, Masiá M, Flores J, Boix V, Merino E, Galindo J, Ortega E, López-Aldeguer J, Galera C. Osteonecrosis in Patients Infected With HIV. J Acquir Immune Defic Syndr 2006; 42:286-92. [PMID: 16763523 DOI: 10.1097/01.qai.0000225012.53568.20] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is a paucity of data on clinical epidemiology of osteonecrosis in HIV-infected patients. We aimed to describe patients' characteristics and natural history of this poorly known condition. METHODS All cases of symptomatic HIV-related osteonecrosis diagnosed from 1990 through 2003 in 19 Spanish clinics were reviewed. Functional status at the last visit was assessed with the validated Western Ontario and McMaster Universities Index questionnaire. RESULTS Of 54 patients analyzed, 29 (53.7%) had a single bone necrosis, and 25 (46.3%) had 2 or more sites involved. Progression of symptoms happened more often in patients with hip involvement (17/39 vs 0/8 patients; P = 0.019). Twenty patients (37%) required surgical intervention. Male sex and higher CD4 cell count were associated with surgery on multivariable analysis. Overall, at the end of the follow-up period, half of the patients had moderate to severe disability (Western Ontario and McMaster Universities Index score > or =60). During a follow-up period of 137 person-years, only 2 new episodes of osteonecrosis were observed (rate of recurrences, 1.5/100 person-years; 95% confidence interval, 0.4-5.1). CONCLUSIONS HIV-related osteonecrosis is associated with significant disability over time. Location of bone necrosis, sex, and CD4 cell count may influence the outcome. The risk for recurrences for patients who have experienced 1 episode is low.
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Affiliation(s)
- Félix Gutiérrez
- Infectious Diseases Unit, Internal Medicine Department, Hospital General Universitario de Elche, Alicante, Spain.
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