Total Joint Arthroplasty in People Living With HIV: An Evidence-Based Surgical Review
Key Takeaway
Total joint replacement is safe for HIV patients with modern ART. Outcomes are comparable to HIV-negative individuals. Surgeons must consider bone quality, avascular necrosis, and meticulous perioperative management for THA/TKA in PLWH, ensuring successful results and debunking outdated complication myths.
You are in a consultant interview. You are presented with a 58-year-old patient with end-stage hip osteoarthritis secondary to avascular necrosis. The patient is HIV positive. The patient is requesting a total hip arthroplasty. How do you approach the risk assessment and decision-making for this candidate?
Candidate: I would start by confirming the patient's HIV status control, specifically their current CD4 count and viral load. I'd seek an infectious disease consultation to ensure they are on stable ART. Provided they are well-controlled, I would proceed with standard arthroplasty protocols but be mindful of higher risks of osteopenia and potential drug interactions.
Candidates often fail to provide specific numerical targets, relying on vague terms like "well-controlled." They also frequently miss the requirement for a multidisciplinary team (MDT) approach and ignore the specific bone quality issues (osteopenia) common in this population that might dictate implant fixation strategy (e.g., cemented vs. cementless).
I would approach this by stating that HIV is no longer a contraindication. I would: 1) Verify Immunology: Require a CD4 count >350 cells/µL and an undetectable viral load (<50 copies/mL) for 3-6 months. 2) Multidisciplinary Optimization: Mandate an Infectious Disease consult to review potential ART-medication interactions. 3) Bone Health: Order a DEXA scan, as ART-associated bone loss is significant. 4) Surgical Planning: Adjust for reduced bone mineral density (cemented vs. uncemented strategy) and meticulous soft-tissue handling to prevent wound complications. I would conclude that with optimization, the patient's PJI and failure rates are equivalent to the general population.
The patient has now been cleared for surgery. During the pre-operative planning, you identify significant bone density loss. How does this influence your intraoperative technique for the total hip arthroplasty, and what are the specific risks you are mitigating?
Candidate: I would be concerned about intraoperative fractures. I'd be very careful with my reaming and broaching techniques, perhaps using cerclage wires prophylactically, and would consider a cemented femoral stem if the press-fit is not solid enough.
The candidate ignores the acetabular side, focusing only on the femur. They also fail to mention the importance of templating the center of rotation to minimize shear forces on potentially weak bone.
In patients with HIV-related osteopenia/osteoporosis, I am mitigating the risk of intraoperative periprosthetic fracture and early aseptic loosening. Intraoperatively: I would employ gentle, incremental reaming of the acetabulum and femoral canal. If press-fit stability is questionable, I would have a low threshold to convert to a cemented stem or use supplementary screw fixation in the acetabulum. I would also use prophylactic cerclage wires if there is any evidence of cortical thinning or stress risers, and ensure precise restoration of the center of rotation and femoral offset to optimize the mechanical environment of the bone-implant interface.
