CORR Insights^®: Risk of Complications After THA Increases Among Patients Who Are Coinfected With HIV and Hepatitis C

Where Are We Now?

In the current study, Mahure and colleagues examined the post-THA complications in patients with human immunodeficiency virus (HIV) and Hepatitis C (HCV) coinfection. The topic is important because these patients often have reduced bone mineral density and an increased risk of hip fractures [7]. Patients with HIV/HCV coinfection generally are younger and male, and they have higher rates of substance abuse, homelessness, psychiatric disorders, and readmission after surgery. In addition, they are at increased risk of having two or more complications after THA and longer hospital stays after surgery compared to patients who do not have HIV or Hepatitis C [7].

Previous studies [1, 5] also found an increased risk of surgical and medical complications for patients with either Hepatitis C or HIV compared to those with neither disease. One administrative database found that 0.47% of the 1,700,400 total joint arthroplasty patients had Hepatitis C [1], but these patients had a 15% higher risk of an inpatient medical complication and a 78% higher risk of an inpatient surgical complication. Furthermore, the mean length of stay was 14% longer in this cohort. Another study from one center found a slightly lower survivorship (96.2% vs. 98.7%) and a higher risk of complications for patients with Hepatitis C when compared to those who did not have the disease, however, this finding did not reach statistical significance [3]. Another administrative database study found that patients with HIV infection were more likely to have major and minor complications, as well as an increased length of stay compared to those who did not have HIV (4.31 vs. 3.83 days) [5]. By contrast, a small study comparing patients with HIV to those without that diagnosis who underwent THA for osteonecrosis found no differences in aseptic loosening or functional outcomes between the groups. Overall, it is evident that the patients who are infected with either Hepatitis C or HIV are at increased risk of developing complications after THA, however, the risk may not be as high as once thought. For patients who are coinfected, however, there is a paucity of studies to make a definitive conclusion about their risk stratification and management.

Where Do We Need To Go?

Currently, it is unknown what specific peri-operative interventions will improve the outcomes of these patients. Studies from other surgical specialties are used to guide peri-operative management. For example, when treating patients with HIV, it is important to measure CD4+ T cell counts because these patients are predisposed to developing surgical site infections when their counts are low [3]. For patients with Hepatitis C, one might consider measuring the viral load using an HCV ribonucleic acid test in order to establish if active infection is present. The anti-HCV antibody test would be inappropriate in these cases, because patients with advanced HIV infection have a high rate of false negative results. Although these tests can give us a general idea of which patients are at increased risk, there is still a paucity of studies that correlate the pre-operative CD4+T cell counts and HCV ribonucleic acid quantities with the outcomes of total joint arthroplasty.

How Do We Get There?

The increased risk of complications for patients with HIV/HCV coinfection may potentially be offset with thoughtful preoperative planning, careful surgical technique, and vigilant postoperative followup. That being said, laboratory tests for the presence of HIV or HCV infection are not routinely performed prior to THA [9] because of high costs. However, patients who are diagnosed with one infection should be tested for the presence of the other because of the high prevalence of coinfection in this patient population (28%) [8].

For patients with coinfection, preoperative assessment should concentrate on reducing the risk factors prevalent in this patient population since they may contribute to poor outcomes and complications. Because patients with HIV/HCV coinfection have a higher rate of substance abuse and psychiatric disorders, clinicians should be mindful of the substance recovery programs available to their patients and perhaps they should consider a psychiatric evaluation as appropriate. In addition, these patients have a higher risk of homelessness and may potentially be at increased risk of developing complications or being readmitted. Therefore, referral to social services should be obtained. Also, close communication with the treating infectious disease specialist is advised. Interferon and antiretroviral therapy carry a high risk of toxicity, including psychiatric illness and cytopenias [6]. Prophylactic administration of erythropoietin may be important prior to the surgery, which could delay the procedure. However, more studies are needed to evaluate the efficacy of these interventions in the lower extremity total joint arthroplasty population.

Immediately, preoperatively, anti-infective prophylaxis may need to be adjusted depending on CD4+ T cell counts in these patients, and should be done on a patient-specific level in collaboration with an infectious disease specialist [4, 10]. Further studies need to be performed in order to stratify total joint arthroplasty patients risk of developing infections based on CD4+T cell count. In addition, careful blood-sparing surgical techniques should be utilized to minimize blood loss in these patients who are at increased risk of developing anemia [6]. A patient-centered approach for discharge planning needs to be initiated on the first postoperative day, in order to keep the length of hospital stay down. After surgery, these patients may require closer-than-usual followup, earlier office visits, and potentially at-home nurse visits in order for early identification and/or prevention of complications and prevention of unnecessary readmissions.