Total joint arthroplasty in human immunodeficiency virus positive patients

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS AND DISCUSSION

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

CONCLUSION

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

Outcome of Surgical Management of Hemophilic Pseudotumor: Review of 10 Cases from Single-Center

Objective

To evaluate the operative methods and clinical results of surgical treatment in a case series of 10 patients with hemophilic pseudotumors.

Methods

Ten patients with hemophilic pseudotumors who received surgical resection treatment in our hospital from October 2017 to June 2020 were retrospectively reviewed. All patients were hemophilia A (factor VIII deficiency).The age range was 20–51 years. Preoperative imaging examination revealed the size of irregular mass from 8.2 cm× 3.3 cm× 2.3 cm to 22.3 cm× 15.5 cm× 17.0 cm. With the supplementary of recombinant coagulation factor VIII, five cases received complete resection; one received resection and skin grafting; one received cytoreduction surgery as the pseudotumor closing to iliac vessel and nerve; three cases received complete resection and construction as bone destruction. The perioperative variables were recorded and all the patients were followed in the outpatient clinic. Clinical and radiological assessments were conducted.

Results

In these patients, the average intraoperative blood loss volume was 783.1 mL (range, 240–2100 mL). Six patients received blood transfusion during perioperative period. The average duration of surgery was 140.7 min (range, 110–240 min). All wounds healed smoothly and there was no infection or chronic sinus formation. The average length of hospital stay was 16.3 days (range, 12–25 days). There is no iatrogenic vascular nerve injury in our series. Complete follow‐up was performed in all patients. Mean follow‐up duration was 14.2 months (range, 6–26 months). One patient with pseudotumor in the thigh had a recurrence 1 year after operation, then secondary operation was performed. In three cases who received complete resection and construction, patient 8 obtained bone graft and late fixation. X‐ray examination showed bone formation in the lesion at the 2‐year follow‐ups after operation. Patient 9 underwent knee replacement, his left knee showed flexion deformity in preoparation. At the last follow‐up, range of motion was improved from 0° to 40° compared with preoperative status. Patient 10 had pseudotumor in the distal femur, received long bone graft and intramedullary nail fixation.

Conclusions

Surgical resection for hemophilic pseudotumors is an effective and safe method. The choice of surgical procedure must be individualized according to the localization and progress of pseudotumor.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, prognostic.

Outcome of total hip and knee arthroplasty in HIV-infected patients: A systematic review

Significant advances in the treatment of Human Immunodeficiency Virus (HIV) have occurred in recent times, with life expectancy now approaching the normal population. Therefore, patients with HIV will increasingly be undergoing joint replacement in the future, however concerns remain regarding the complications and outcome in this patient cohort. The aim was to assess the outcome of total hip and knee arthroplasty in HIV-infected patients. A systematic search of the literature using MOOSE reporting guidelines was performed to assess the outcome of hip and knee arthroplasty in HIV-infected patients. The primary outcome was infection. Secondary outcome was all-cause revision. The search yielded 552 results, of which 19 met the inclusion criteria, comprising 5.819.412 joint replacements. The overall quality of the studies was poor with significant heterogeneity between the studies. Infection and revision appeared to be more likely to occur in HIV positive patients compared to HIV negative patients. A subgroup analysis of four studies revealed a risk ratio of 3.31 and 2.25 for increase in infection and revision respectively in HIV positive patients. This systematic review and meta-analysis demonstrates an increased risk of infection and revision in HIV infected patients undergoing total hip and knee arthroplasty. However, these findings are based on poor quality evidence in a limited number of studies and need to be interpreted with caution. Further research should concentrate on large, well-designed, prospective studies, that control for co-morbidities and employ standardised outcome measures to allow for direct comparison.

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

BACKGROUND

Advancements in the management of human immunodeficiency virus (HIV) now permit HIV-positive patients to have longer life spans, increasing their cumulative risk of developing an advanced degenerative joint disease, necessitating total hip arthroplasty (THA). The purpose of this study was to provide an extended follow-up on a previously published study on a cohort of HIV-positive THA recipients in an effort to confirm the safety and longevity of THA in this population.

METHODS

This study is a follow-up on a previous study comprised of 41 hips in 31 HIV-positive THA recipients. At this follow-up, 5 patients from the original cohort required contralateral THA. Postoperative complications were recorded up to the patient's last follow-up date. A survivorship analysis was performed using the Kaplan-Meier method with revision THA as the end point.

RESULTS

Since the last report, 2 additional hips were revised (one for aseptic loosening and one for a periprosthetic fracture), and 5 patients underwent contralateral THA. This resulted in a total of 5 (13.8%) hips requiring revision THA at the latest follow-up. The mean follow-up interval for the original cohort and for the contralateral 5 hips was 78.9 ± 50.2 months and 54.6 ± 45.3 months, respectively. Kaplan-Meier survivorship analysis with revision THA for any reason as the end point demonstrated survivorship of 93% (2 years), 90% (5 years), and 81% (10 and 14 years) after primary THA, respectively.

CONCLUSION

Our study suggests that it is possible to achieve a low incidence of postoperative infection in HIV-positive THA recipients. In addition, our study demonstrates that non-hemophiliac HIV-positive patients have comparable revision rates to previously published reports on HIV-negative patients of similar age, underscoring the clinical efficacy of highly active antiretroviral therapy.

Control Strategies for Infection Prevention in Total Joint Arthroplasty

Despite the development of newer preventative measures, the rate of infection continues to be approximately 1% for patients undergoing total joint arthroplasty (TJA). The extent of the infection can range from a mild superficial infection to a more serious periprosthetic joint infection (PJI). PJIs not only play a significant role in the clinical well-being of the TJA patient population, but also have substantial economic implications on the health care system. Several approaches are currently being used to mitigate the risk of PJI after TJA. The variety of prophylactic measures to prevent infection after TJA must be thoroughly discussed and evaluated.

Short and Long-Term Postoperative Complications Following Total Joint Arthroplasty in Patients With Human Immunodeficiency Virus, Hepatitis B, or Hepatitis C

INTRODUCTION

Due to advancement in treatment against human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), the prevalence of this patient population electing to undergo total joint arthroplasty (TJA) is increasing. Current literature is scarce and conflicting especially when evaluating long-term surgical complications. The purpose of this study is to assess the postoperative medical and surgical complications following TJA in these patient populations.

METHODS

Using a nationwide database between 2005 and 2012, 4 cohorts were created: patients with HIV, HCV, HBV, and HIV and HBV or HCV who underwent TJA. Cohorts were matched to a control group by age, gender, and Charlson Comorbidity Index. Thirty-day and 90-day medical complications and 90-day and 2-year surgical complications were evaluated using odds ratios with 95% confidence intervals.

RESULTS

Following TJA, patients with HCV or HBV had increased risk of pneumonia, sepsis, joint infection, and revision surgery at 90 days and 2 years. Patients with HIV did not have increased risk of infection at 90 days and 2 years but did have increased risk of revision at 90 days (odds ratio 3.21, 95% confidence interval 1.31-7.84) following total hip arthroplasty.

CONCLUSIONS

Patients with HIV, HBV, or HCV have an overall increased risk of postoperative medical and surgical complications following TJA. Patients with HBV or HCV are at risk of more complications than patients with HIV especially for infection within 90 days after TJA. Patients with HIV are at risk of mechanical complications but do not appear to be at significant risk for infection following total hip arthroplasty.

Total knee arthroplasty in patients with a history of illicit intravenous drug abuse

PURPOSE

Injection drug users are at high risk for both infection with blood-borne pathogens, namely, human immune deficiency virus (HIV), hepatitis-B, -C virus, various bacterial infections, as well as early primary and secondary joint degeneration. When total knee arthroplasty (TKA) is anticipated the risk of septic complications is a major concern. The purpose of this study was to assess the clinical and radiographic outcome of patients with a history of intravenous drug use after total knee arthroplasty. The primary outcome was revision rate. Secondary outcomes were the Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Society Score (KSS) and radiographic loosening.

METHODS

We retrospectively reviewed the records of 1,692 TKA performed or revised in our institution. Data of 18 TKA in 12 patients (11 male, 1 female; average age 42, range 23-62 years) with a history of intravenous opioid abuse were available for final analysis.

RESULTS

The mean follow up was 125 (range 25-238) months. Seven patients required revision surgery due to periprosthetic joint infection after 62 months (range 5-159): one two staged revision, three arthrodesis and three amputations. The median prosthesis survival was 101 (95%-CI 48-154) months.

CONCLUSION

Total knee arthroplasty in patients with a history of intravenous drug abuse is associated with major complications, including above-the-knee amputation. If permanent abstinence from intravenous drug abuse is doubtful, other therapeutic options including primary arthrodesis should be considered.

Human Immunodeficiency Virus and Total Joint Arthroplasty: The Risk for Infection Is Reduced

BACKGROUND

Highly active antiretroviral therapy (HAART) has changed the face of human immunodeficiency virus (HIV) and allowed patients to live for many decades. HIV and HAART are known risk factors for osteonecrosis of bone, osteopenia, and osteoporosis. Therefore, the demand for total joint arthroplasty (TJA) in HIV-infected patients is on the rise. We attempted to determine whether modern treatments for HIV have impacted the rate of periprosthetic joint infection (PJI).

METHODS

Conducting a systematic review, 25 studies with a total of 722 TJAs were identified. We extracted data on rates of PJI after primary TJA in HIV-infected patients with and without hemophilia and data on administration of HAART at the time of arthroplasty.

RESULTS

Three hundred eighty-one TJAs were performed in 293 patients with HIV infection without hemophilia. The follow-up ranged between 1.5 months and 11 years. Nine patients developed PJI. In patients with both HIV and hemophilia, 341 primary TJAs were performed. Forty-five received treatment for PJI. Follow-up ranged between 1 year and 26 years. Rates of PJI were 2.28% and 10.98% for HIV-only patients and patients with HIV and hemophilia, respectively. This difference was statistically significant (P < .0001) with a 5.28 odds ratio for hemophilia. HAART was associated with fewer infections overall (odds ratio, 0.12).

CONCLUSION

The rates of PJI after TJA in HIV-only patients are lower than those in patients with both HIV and hemophilia. Treatment of patients with HAART and optimization of underlying comorbidities appears to lower the rate of PJI in this patient population.

Does HIV Infection Increase the Risk of Short-Term Adverse Outcomes Following Total Knee Arthroplasty?

Using the Nationwide Inpatient Sample, we assess the: (1) demographic trends; (2) complications; and (3) length of hospital stay among total knee arthroplasty (TKA) patients with and without human immunodeficiency virus (HIV). The study population consisted of 2772 patients with HIV and 5,672,314 controls. Patients with HIV were more likely to be younger, male, and nonwhite. Patients with HIV were at an increased risk for perioperative wound infections (OR=2.78; P=0.024), although they were not at an increased risk for overall complications (OR=1.21; P=0.321). Mean length of stay was 17% longer for patients with HIV (P<0.001). Given these findings, orthopedic surgeons should have a low threshold to work up a patient with HIV for a wound infection following TKA.

Does HIV infection increase the risk of perioperative complications after THA? A nationwide database study

BACKGROUND

Recent studies have shown successful midterm outcomes after total hip arthroplasty (THA) in patients with human immunodeficiency virus (HIV). However, little data exist on the epidemiology, risk of perioperative complications, and length of stay in patients with HIV receiving THA.

QUESTIONS/PURPOSES

The purposes of this study were to assess (1) the demographic trends of patients with HIV who underwent primary THA; (2) the differences in the risk of major and minor perioperative complications among patients with and without HIV; and (3) the differences in mean length of hospital stay among patients with and without HIV.

METHODS

The Nationwide Inpatient Sample was used to compare patients with and without HIV who were admitted for THA between 1998 and 2010 in the United States. We extracted data on each admission's age, sex, race, insurance, and comorbidities. The study population consisted of 2,656,696 patients without HIV and 9275 patients with HIV.

RESULTS

Patients with HIV were more likely to be younger, be male, not pay with Medicare, and be of a nonwhite race. After controlling for confounding variables, patients with HIV were more likely to have major complications (2.9% [266 of 9275] versus 2.7% [71,952 of 2,656,696]; odds ratio [OR], 1.47; 95% confidence interval [CI], 1.08-2.00; p=0.014) and minor complications (5.2% [483 of 9275] versus 4.8% [127,940 of 2,656,696]; OR, 1.61; 95% CI, 1.29-2.02; p<0.001) compared with patients who did not have HIV. Patients undergoing THA who had HIV also had an increased length of hospital stay compared with patients without HIV (4.31 versus 3.83 days, p<0.001).

CONCLUSIONS

Given these findings, we believe orthopaedic surgeons should be aware of the potential for longer and more complicated hospital stays after THA among patients with HIV. However, the modest increase in risk of adverse outcomes does not cause us to recommend against THA for patients with HIV who otherwise meet reasonable surgical indications. Future studies should explore the relationships between markers of HIV severity and risk of adverse outcomes after THA during the hospital stay and followup.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.