TKR in patients with HIV and hepatitis C

A 56-year-old man who is hepatitic C and HIV positive and currently taking HAART presents to your clinic to discuss total hip arthroplasty. He states that he is concerned that being HIV positive will increase his risk of complications after total hip arthroplasty.

You inform him that:

1. HIV-positive status is an independent risk factor for complication after total joint arthroplasty

2. He has a higher risk of prosthetic joint infection

3. He has a higher risk of superficial wound infection requiring irrigation and debridement

4. Patient satisfaction after total hip arthroplasty is lower in patients with HIV

 

Discussion

The correct answer is (C). Historical studies of arthroplasty in HIV-positive patients showed an increased risk of perioperative complication, but these data tend to come from smaller series that focused on patients with a history of hemophilia or intravenous drug use, which have been shown to play a larger role in complication rates than HIV itself. Recent studies show that there is no difference in the overall rate of perioperative complication in HIV-positive patients undergoing total hip or knee arthroplasty. HIV-positive status does put patients at higher risk for certain complications including acute renal failure and superficial wound infection requiring irrigation and debridement.

What is the most likely source of hip arthropathy in this patient?

1. HAART related AVN of the femoral head

2. Hepatitis C–related AVN of the femoral head

3. CAM impingement

4. Trauma

 

Discussion

The correct answer is (A). There is a well-established association between longterm antiretroviral use and osteonecrosis of the femoral head in patients with a diagnosis of HIV. The exact mechanism by which these medications cause AVN remains unknown. In cases in which there is a systemic cause of AVN, 50% to 80% can be bilateral therefore an MRI should be performed on the asymptomatic side to rule out precollapse disease. In patients in whom the femoral head has not collapsed, core decompression is recommended. Those that have femoral head collapse are best treated with arthroplasty.

There is a higher likelihood of mechanical failure and infection in this patient due to which of the following reasons?

1. Male gender

2. Tall height

3. HIV infection

4. Hepatitis C infection

5. Antiretroviral use

 

Discussion

The correct answer is (D). In a study by Pour et al. a group of patients with Hepatitis C who underwent THR were found to have an increased incidence of implant loosening, dislocation, fractures, wound complications, and deep infection. The reason for this is unknown. Patients with hepatitis C were also found to have longer hospital stays and higher rates of reoperation and revision. As mentioned above, contemporary studies regarding patients with HIV who undergo THR have not shown a difference in infection and mechanical failure rates in patients with HIV in comparison to controls. Tall height and male gender have not been linked to mechanical failure or infection following THR.

 

Objectives: Did you learn...?

 

 

The risks associated with TKR in patients with HIV and hepatitis C? Increase in wound complications in the HIV patient?

 

The causes of AVN in the HIV-infected patient?