1. 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

2. We have nothing to Disclose
Disclosures
We have nothing to Disclose

3. 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

4. -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 Nov;57(11):

5. 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 Mar;1:44 (5): , Yombi et al. Clin Rheum Jul; 28 (7): Ries et al. J Arthroplasty Feb; 17(2): Allison et al. AIDS.2003 Jan 17(1): 1-9.

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

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

8. Early Literature Lehman et al. 2001
28 HIV + patients underwent TJA
4 (14%) developed infections
Haberman et al. 2008
55 TJAs in HIV + patients from
12.7 % developed deep infections
Higher rate of infections with IVDA
Parvizi et al
21 TJA in 15 HIV+ patients from
6 Deep infections, 13 repeat surgeries
1. Lehman et al. J Arthroplasty (3): Haberman et al. J of infection ; Parvizi et al. J Arthroplasty (3) ; 259.

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

10. Tornero et al. HIV Medicine. 2012. 13: 623-629.
Current Literature
Tornero et al. 2012
18 THA in 13 HIV + patients with AVN
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 :

11. 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.

12. 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 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:

13. Capogna et al. J Arthroplasty. 2013; 29: 125401258.
Retrospective chart review 69 TJA in 57 HIV + patients from
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:

14. 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.

15. 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

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

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

18. 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

19. HIV patient Data <200 200-500 >500 CD 4 count 9 12 <50 50-5009 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%)

20. 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 ( )
499 ( )
540 ( )
0.4
Length of Stay (days)
6.3 (2-23)
4.6 (1-20)
5.6 (2-23)
0.13

21. 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

22. 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 :

23. 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 : Lin et al. J Arthroplasty. 2013: E publication.

24. 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

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

26. 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