Postoperative outcomes in total hip arthroplasty following femoral head avascular necrosis in HIV-positive patients.

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Alfonso Manzotti
Marco Larghi
Emanuele Placenza
Francesca Susini
Miriam Grassi


Osteonecrosis, avascular necrosis, femoral head, HIV, Hip Arthroplasty, Total Hip Replacement, complications


Background: Few clinical studies have been published reporting the clinical outcomes of total hip replacement (THA) in HIV-positive patients affected by femoral head avascular necrosis (AVN) often with controversial results and often without any correlation with the immunological patient status. Our study aim is to retrospectively review the outcome of a HIV-positive patient series. Material and Methods: 24 THAs perfomed between 2007 and  2017 were assessed in the study. All patients have been classified with Charlson Comorbidity Index (CCI) and the CDC (Center for Disease Control and Prevention) HIV classification.  At the latest follow-up each patient have been evaluated using Harris Hip Score (HHS), WOMAC score, a numerical pain rating scale (NRS) and procedure-related complications were collected. Results:At a mean mean follow up of 96,41 months the mean WOMAC score was 91,66  and the mean Harris Hip Score was 86,77 with  excellent results in 18 hips, good in 1 and poor in the 5. Post-operative complications were reported in 7 hips, 3 patients developed a periprosthetic joint infection (PJI) in patients with low CD4+ count and history of intravenous drug consumption. Conclusion: We registered a good outcome in HIV patient with femoral head AVN treated with Total Hip replacement. However, we reported a significant increase in complications and revision rate especially referred to PJI, in patient with history of intravenous drug consumption and low CD4+ count. The authors advocate further prospective multicentric studies with larger population in the future. (


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1. Morse CG, Mican JM, Jones EC, Joe GO, Rick ME, Formentini E, Kovacs JA. The incidence and natural history of osteonecrosis in HIV-infected adults. Clin Infect Dis. 2007 Mar 1;44(5):739-48. Epub 2007 Jan 23. PubMed PMID: 17278070.
2. Permpalung N, Ungprasert P, Summachiwakij S, Leeaphorn N, Knight EL. Protease inhibitors and avascular necrosis: a systematic review and meta-analysis. Int JAntimicrob Agents. 2014 Aug;44(2):93-5. doi: 10.1016/j.ijantimicag.2014.02.011. Epub 2014 Mar 28. Review. PubMed PMID: 24726526.
3. Mehta P, Nelson M, Brand A, Boag F. Avascular necrosis in HIV. Rheumatol Int. 2013 Jan;33(1):235-8. doi: 10.1007/s00296-011-2114-5. Epub 2011 Sep 22. PubMedPMID: 21938549.
4. Abbas-Zadeh MR, Azizi A, Abbas-Zadeh L, Amirian F. Effect of surgical treatment on the quality of life in patients with non-traumatic avascular necrosis of the femoral head. Rev Bras Ortop. 2018;53(6):773–777. Published 2018 Feb 3. doi:10.1016/j.rboe.2017.08.021
5. Singh JA, Chen J, Inacio MC, Namba RS, Paxton EW. An underlying diagnosis of osteonecrosis of bone is associated with worse outcomes than osteoarthritis after total hip arthroplasty. BMC Musculoskelet Disord. 2017;18(1):8. Published 2017 Jan 9. doi:10.1186/s12891-016-1385-0
6. Waewsawangwong W, Ruchiwit P, Huddleston JI, Goodman SB. Hip arthroplasty for treatment of advanced osteonecrosis: comprehensive review of implant options, outcomes and complications. Orthop Res Rev. 2016;8:13–29. Published 2016 Jun 28. doi:10.2147/ORR.S35547
7. O'Neill SC, Queally JM, Hickey A, Mulhall KJ. Outcome of total hip and knee arthroplasty in HIV-infected patients: A systematic review. Orthop Rev (Pavia). 2019;11(1):8020. Published 2019 Mar 22. doi:10.4081/or.2019.8020
8. Lin CA, Takemoto S, Kandemir U, Kuo AC Mid-Term Outcomes in HIV-positive patients After Primary Total Hip or Knee Arthroplasty. J Arthroplasty 2014; 29:277-282.
9. Zhao CS, Li X, Zhang Q, Sun S, Zhao RG, Cai J. Early Outcomes of Primary Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Patients with Human Immunodeficiency Virus in China. Chin Med J (Engl). 2015;128(15):2059–2064. doi:10.4103/0366-6999.161364
10. Chokotho L, Harrison WJ, Lubega N, Mkandawire NC. Avascular necrosis of the femoral head in HIV positive patients-an assessment of risk factors and early response to surgical treatment. Malawi Med J. 2013;25(2):28–32.
11. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. JChronic Dis. 1987;40(5):373-83. PubMed PMID: 3558716.
12. Manenti G, Altobelli S, Pugliese L, Tarantino U. The role of imaging in diagnosis and management of femoral head avascular necrosis. Clin Cases Miner Bone Metab. 2015;12(Suppl 1):31–38. doi:10.11138/ccmbm/2015.12.3s.031
13. UNAIDS UNAIDS Data 2018. Available at: ( accessed January 2020).
14. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR Recomm Rep. 1992 Dec 18;41(RR-17):1-19. PubMed PMID: 1361652.
15. Günthard HF, Saag MS, Benson CA, et al. Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2016 Recommendations of the International Antiviral Society-USA Panel. JAMA. 2016;316(2):191–210. doi:10.1001/jama.2016.8900
16. Chang CH, Tsai SW, Chen CF, Wu PK, Wong WW, Chang MC, Chen WM. Optimal timing for elective total hip replacement in HIV-positive patients. Orthop Traumatol Surg Res. 2018 Sep;104(5):671 674. doi: 10.1016/j.otsr.2018.05.005. Epub 2018 Jun 28. PubMed PMID: 29908354.
17. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969 Jun;51(4):737-55.
18. Klassbo M, Larsson E, Mannevik E. Hip disability and osteoarthritis outcome score. An extension of the Western Ontario and McMaster Universities Osteoarthritis Index. Scand J Rheumatol. 2003;32(1):46-51.
19. De Luca ML, Ciccarello M, Martorana M, et al. Pain monitoring and management in a rehabilitation setting after total joint replacement. Medicine (Baltimore). 2018;97(40):e12484. doi:10.1097/MD.0000000000012484
20. Healy WL, Iorio R, Clair AJ, Pellegrini VD, Della Valle CJ, Berend KR. Complications of Total Hip Arthroplasty: Standardized List, Definitions, and Stratification Developed by The Hip Society. Clin Orthop Relat Res. 2016 Feb;474(2):357-64. doi: 10.1007/s11999-015-4341-7. PubMed PMID: 26040966; PubMed Central PMCID: PMC4709292.
21. 22. Enayatollahi MA, Murphy D, Maltenfort MG, Parvizi J. Human Immunodeficiency Virus and Total Joint Arthroplasty: The Risk for Infection Is Reduced. J Arthroplasty. 2016 Oct;31(10):2146-51. doi: 10.1016/j.arth.2016.02.058. Epub 2016 Mar 10. Review. PubMed PMID: 27131415.
22. 23. O'Neill SC, Queally JM, Hickey A, Mulhall KJ. Outcome of total hip and knee arthroplasty in HIV-infected patients: A systematic review. Orthop Rev (Pavia). 2019;11(1):8020. Published 2019 Mar 22. doi:10.4081/or.2019.8020
23. 24. ISSN. Supplemento del notiziario dell’Istituto Superiore di Sanità. Aggiornamento delle nuove diagnosi di infezione da HIV e dei casi di AIDS in italia al 31 dicembre 2017. Volume 31 numero 9 ISSN 1827-6296
24. Ancelin D, Reina N, Cavaignac E, Delclaux S, Chiron P. .Total hip arthroplasty survival in femoral head avascular necrosis versus primary hip osteoarthritis: Case-control study with a mean 10-year follow-up after anatomical cementless metal-on-metal 28-mm replacement. Orthop Traumatol Surg Res. 2016 Dec;102(8):1029-1034. doi: 10.1016/j.otsr.2016.08.021. Epub 2016 Oct 27
25. Tornero, E., García, S., Larrousse, M., Gallart, X., Bori, G., Riba, J., Rios, J., Gatell, J. and Martinez, E. (2012), THA in HIV‐infected patients: controlled study. HIV Med, 13: 623-629. doi:10.1111/j.1468 1293.2012.01017.x
26. Falakassa J, Diaz A, Schneiderbauer M. Outcomes of total joint arthroplasty in HIV patients. Iowa Orthop J. 2014;34:102-6. PubMed PMID: 25328467; PubMed Central PMCID: PMC4127742.
27. Guild GN, Moore TJ, Barnes W, Hermann C. CD4 count is associated with postoperative infection in patients with orthopaedic trauma who are HIV positive. Clin Orthop Relat Res. 2012 May;470(5):1507-12. doi: 10.1007/s11999-011-2223-1. Epub 2011 Dec 30. PubMed PMID: 22207561; PubMed Central PMCID: PMC3314762.
28. Tan TL, Maltenfort MG, Chen AF, Shahi A, Higuera CA, Siqueira M, Parvizi J. Development and Evaluation of a Preoperative Risk Calculator for Periprosthetic Joint Infection Following Total Joint Arthroplasty. J Bone Joint Surg Am. 2018 May 2;100(9):777-785. doi: 10.2106/JBJS.16.01435. PubMed PMID: 29715226.