Avascular necrosis: a growing concern for the HIV population

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.

Joint replacement for avascular necrosis in people living with HIV

Recently, the interest on multifocal avascular necrosis (AVN) among people living with HIV (PLWH) is rising. PLWH have an incidence of symptomatic AVN significantly higher than the general population. The chronic viral infection may induce a direct damage via necrotizing vasculitis, on the other hand the highly active antiretroviral therapy represents a probable risk factor as it can indirectly lead to multifocal necrosis. Regardless of etiopathology, the AVN management in PLWH is the same as in the general population. Depending on symptoms, stage, and location, the AVN can be treated conservatively or surgically, but in its final stages joint replacement is often the most appropriate therapeutic option. The safety and outcomes of such major orthopedic surgery in PLWH are debated topics. In agreement with the literature in our case series we observed, despite some complication, a significant pain relief and excellent recovery of function after hip replacements. Although increased complication rates, several other independent risk factors associated with HIV infection can act as confounding factors. These confounders must be taken into account both in clinical practice and in data analysis. This case-based review highlights the increasing incidence of AVN in PLWH, and emphasizes the safety and effectiveness of the prosthetic joint replacement in this population.

Rapid onset avascular necrosis secondary to misuse of appetite stimulant

BACKGROUND

HIV patients often fear disclosure of their status and consequently are fearful that their appearance may lead people to believe they have HIV. Excessive attention to weight is one result.

CASE PRESENTATION

We present a case of bilateral avascular necrosis (AVN) of the femoral heads secondary to megestrol misuse. Multiple providers with non-communicating electronic medical records contributed to this event, especially in our patient who was a guarded historian. Because of altered body image and fear of HIV disclosure, our patient who was already prescribed an antiretroviral associated with decreased bone density, sought an appetite stimulant and used far more than the prescribed dose leading to rapid onset AVN.

CONCLUSIONS

Use of appetite stimulants in HIV should be carefully monitored and utilized only when weight loss is excessive and documented, and steroid based appetite stimulants should be avoided.