Total Hip Arthroplasty in HIV Positive Patients Catherine J. Fedorka MD, Nader Toossi MD, Gregory Kanski BS, Douglas Cerynik MD, Norman A Johanson MD Hahnemann University Hospital/Drexel University College of Medicine

We have nothing to Disclose Disclosures We have nothing to Disclose

Introduction Human Immunodeficiency Virus (HIV) is estimated to affect 1.5 million people in North America and 33 million people worldwide -UNAIDS Report on Global Epidemic 2010 Since the development of highly active antiretroviral therapy (HAART) in 1997, medical management of HIV patients is much improved

-Kirk and Goetz J Am Geriatr Soc. 2009 Nov;57(11):2129-38. HIV and Aging It is estimated that by 2015, 50% of those living with HIV will be 50 years old or older -Kirk and Goetz J Am Geriatr Soc. 2009 Nov;57(11):2129-38.

AVN and HIV HIV positive patients have an increased risk of avascular necrosis (AVN) of their major joints 1. Morse et al. Clin Infect Disease. 2007 Mar;1:44 (5):739-48. 2, Yombi et al. Clin Rheum. 2009 Jul; 28 (7): 815-23. 3. Ries et al. J Arthroplasty. 2002 Feb; 17(2): 135. 4. Allison et al. AIDS.2003 Jan 17(1): 1-9.

The literature has been controversial with regards to the risk of complications in HIV positive patients undergoing total joint arthroplasty (TJA)

Early Literature The early literature showed a high rate of complications in the HIV positive patients undergoing TJA

Early Literature Lehman et al. 2001 28 HIV + patients underwent TJA 1993-1995 4 (14%) developed infections Haberman et al. 2008 55 TJAs in HIV + patients from 1988-2000 12.7 % developed deep infections Higher rate of infections with IVDA Parvizi et al. 2003 21 TJA in 15 HIV+ patients from 1979-1998 6 Deep infections, 13 repeat surgeries 1. Lehman et al. J Arthroplasty. 2001. 16 (3): 330 2. Haberman et al. J of infection. 2008. 57; 41-46. 3. Parvizi et al. J Arthroplasty. 2003. 18 (3) ; 259.

Current Literature The current literature (since the advent of HAART) has shown improved outcomes of HIV positive patients undergoing TJA

Tornero et al. HIV Medicine. 2012. 13: 623-629. Current Literature Tornero et al. 2012 18 THA in 13 HIV + patients with AVN 2001-2010 2:1 HIV negative controls with AVN No significant difference in OR time or length of stay HIV patients were well controlled Average CD4 count: 434 ± 256 Viral load <50 in all patients except 1 (viral load 1250) No infections in HIV+ patients, 2 wound infections in HIV negative patients. Tornero et al. HIV Medicine. 2012. 13: 623-629.

Lin et al. J Arthroplasty. 2013: E publication. Retrospective review of 22 TJAs in 20 HIV+ patients compared with 372 TJA in 355 HIV negative patients 9.1% revision for infection in HIV positive vs 2.2 % in HIV negative group. 9.1% overall revisions in HIV positive vs 5.4 % in HIV negative group No significant difference in revision or infection rate. Lin et al. J Arthroplasty. 2013: E publication.

Lin et al. J Bone Joint Surg Am. 2013; 95: 1028-1036. Current Literature Lin et al. JBJS 2013 Studied 8229 HIV + patients undergoing TJA from 2000-2008 using National Inpatient Sample database HIV+ patients 0.14% of all TJA patients HIV+ patients more likely to: (p<0.05) Develop ARF Develop a wound complication (0.6% vs 0.3%) Undergo a postoperative I&D (0.2 % vs 0.1%) No difference in total complications (8.3% vs 7.9%) HIV not an independent risk factor for complications Lin et al. J Bone Joint Surg Am. 2013; 95: 1028-1036.

Capogna et al. J Arthroplasty. 2013; 29: 125401258. Retrospective chart review 69 TJA in 57 HIV + patients from 1998-2011 2:1 HIV negative controls Only 55% HIV+ and 67% of controls have > 1 year follow-up Deep infection rate 4.4 % vs 0.72% in controls (p=0.11) HIV patients 6.22 times more likely to get infected but this was not statistically significant Capogna et al. J Arthroplasty. 2013; 29: 125401258.

Purpose To perform a retrospective cohort study of HIV positive patients undergoing total hip arthroplasty (THA) and evaluate their operative course and risk of complications, specifically infections.

Methods THA database Queried for all serologically proven HIV positive patients from 2003 to 2012 undergoing primary THA Highly pair matched controls (1:1) were selected based on Age Race Gender Preoperative Diagnosis

Methods Data points collected Demographic data ASA Intraoperative data (EBL, operative time) Intraoperative and postoperative complications Length of stay Follow-up

Patients Thirty-two THAs were performed on 26 HIV positive patients from 2003-2012 9 females; 17 males Matched with 32 THAs in 29 HIV negative patients.

Demographics HIV positive HIV negative Total P=value Age (years) 45.3 (26-69) 44.9 ( 26-68) 45.1 (26-69) 0.84 BMI 26.8 (19-45) 28.3 (21-40) 27.5 (19-45) 0.32 ASA 2.73 (2-4) 2.37 (1-4) 2.55 (1-4) 0.34 AVN 21 23 44 0.79 Follow-up (months) 29.2(2-77) 46.5 (2-118) 66.1 (9-129) 0.04

HIV patient Data <200 200-500 >500 CD 4 count 9 12 <50 50-500 9 12 <50 50-500 >500 Viral Load 9 7 5 25/26 HIV positive patients were on HAART at the time of TJA NRTI NNRTI PI 3 (9.4%) 25 (78.1%) 7 (21.9%) 1 3 (9.4 %) 5 (15.6%) 2 26 (81.3%) 20 (62.5%)

Estimated Blood Loss (cc) Operative Data HIV positive HIV negative Total P-value Operative Time (min) 99.6 (66-219) 92.4 (55-176) 96.0 (55-219) 0.33 Estimated Blood Loss (cc) 457 (200-1000) 499 (200-2800) 540 (200-2800) 0.4 Length of Stay (days) 6.3 (2-23) 4.6 (1-20) 5.6 (2-23) 0.13

Complications 4 (12.5%) total complications in the HIV positive group vs 3 (9.4%) complications in HIV negative group (p=0.58) 1/32 (3%) infections HIV + vs 2/32 (6%) HIV neg (p=0.51) Complication HIV (+) HIV (-) Superficial Infection 1 Deep Infection Aseptic Loosening requiring revision Heterotopic ossification requiring excision Dislocations

Tornero et al. HIV Medicine. 2012. 13: 623-629 Discussion No significant difference was found between HIV positive and HIV negative patients in operative time, EBL, or length of stay. Tornero et al also found no difference in operative time or hospital duration between HIV positive and HIV negative patients. Tornero et al. HIV Medicine. 2012. 13: 623-629

Discussion 1 superficial infection occurred in HIV+ group (3%) vs 1 superficial and 1 deep in the HIV negative group (6.3%). These results are similar to Tornero et al and Lin et al who found no significant increase in infection risk in HIV + patients Tornero et al. HIV Medicine. 2012. 13: 623-629.. Lin et al. J Arthroplasty. 2013: E publication.

Metaanalysis No infection Infection HIV + (n=141) 135 6 Total patients Infections P value Capogna et al. HIV + 69 3 HIV Neg 138 1 0.11 Tornero et al. 18 HIV negative 36 2 Lin et al. 22 372 8 0.102 Fedorka et al. 32 0.51 TOTAL 141 6 (4.2%) HIV Negative 560 13 (2.3%) 0.163 No infection Infection HIV + (n=141) 135 6 HIV negative (n=560) 547 13

Conclusion HIV patients do not have a higher rate of complications or increased rate of infections when compared with similar HIV negative patients.

Future Research All of the literature to date have been small (<100 pts) retrospective studies of HIV positive patients undergoing TJA The only large patient volume study was a database study A prospective, multicenter study of all HIV positive patients undergoing TJA with long term follow-up is warranted to further determine the risk of complications and their overall outcomes after TJA