Complications due to HIV in patients undergoing total joint arthroplasty: A systematic review and meta-analysis

Ramish Sumbal; Saad Ashraf; Anusha Sumbal; Uooja Devi; Md Ariful Haque

doi:10.1016/j.jor.2024.11.004

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64 (); 39-46

doi:

10.1016/j.jor.2024.11.004

Complications due to HIV in patients undergoing total joint arthroplasty: A systematic review and meta-analysis

Ramish Sumbal^a, Saad Ashraf^a, Anusha Sumbal^a, Uooja Devi^a, Md Ariful Haque^b,c,d,

a Dow University of Health Sciences, Baba-E-Urdu Road, Karachi, 74200, Pakistan

b Department of Orthopaedic Surgery, Yan'an Hospital Affiliated to Kunming Medical University, Kunming, Yunnan, China

c Voice of Doctors Research School, Dhaka, Bangladesh

d Department of Public Health, Atish Dipankar University of Science and Technology, Dhaka, Bangladesh

⁎Corresponding author: Md Ariful Haque. Arifulhaque58@gmail.com

Received: 2024-9-15, Accepted: 2024-11-6, Published: 2024-11-16

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

HIV infection in patients undergoing Total joint arthroplasty (TJA) results in adverse postoperative outcomes. However, there are uncertain data regarding the extent of involvement of HIV in TJA and the individual complications associated with it. Therefore, we planned to conduct a systematic review and meta-analysis to assess the risk of HIV in causing complications after TJA.

Electronic databases such as PubMed, Cochrane, and Google Scholar from inception till May 1, 2023. Studies evaluating complications in HIV-infected patients following TJA were selected. Statistical Analysis was performed through Revman.

A total of 16 studies evaluating 17,974,549 patients were included in the meta-analysis. HIV-infected patients were at increased risk of developing infectious complications (OR 1.82 [1.49, 2.22]; p < 0.00001; I² = 62 %), medical complications (OR 1.85 [1.41, 2.42]; p < 0.00001; I² = 82.8 %) and surgical complications (OR 1.58 [1.38, 1.82]; p < 0.00001; I² = 76 %) following TJA. On subgroup analysis, we found that there was an increased risk of infectious (OR 1.67 [1.19, 2.34]; p = 0.003; I² = 70 %), medical (OR 1.24 [1.03, 1.48]; p = 0.02; I² = 79 %) and surgical complications (OR 1.35 [1.09, 1.67]; p = 0.007; I² = 69 %) following Total knee arthroplasty. As well as there was an increased risk of infectious (OR 1.76 [1.26, 2.46]; p = 0.0001; I² = 0 %), medical (OR 1.54 [1.12, 2.12; p = 0.007; I² = 85 %), and surgical complications (OR 1.50 [1.22, 1.86]; p = 0.0002; I² = 0 %) following Total hip arthroplasty.

HIV-infected patients are at an increased risk of complications following TJA. Knowledge regarding these individual complications will result in better monitoring and post-operative care.

Keywords

Total joint arthroplasty

HIV

Human immunodeficiency virus

Complications

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1 Introduction

Total Joint Arthroplasty (TJA) has become an increasingly popular surgical approach to attenuate pain in a patient with chronic inflammation of joints.¹ With successful pain relief and minimal invasion, total joint arthroplasty is the foremost choice of surgeons nowadays.¹ However, the presence of comorbid conditions such as diabetes, obesity, hypertension, and any chronic infection can elevate the risk of post-surgical complications in recipients of TJA.²^,³ Among the infectious diseases, HIV stands out to be the most potent contributor to post-surgical complications.²^,³

The global prevalence of HIV infection is tremendous. Around 33 % of HIV-infected individuals undergo total joint arthroplasty. Still, unfortunately, a high incidence of post-surgical complications in these patients is a rising concern among surgeons, making them reluctant toward this treatment option.⁴ The risk of developing complications after joint replacement spikes up to 50 % in HIV patients.²^,³ This increasingly rising trend in complications after TJA, particularly in HIV-positive patients is alarming.²^,³

Management of post-arthroplasty complications In HIV patients is still a big challenge for the healthcare provider. One possible reason for this failure is that we lack adequate knowledge. Complications mentioned in post-operative guidelines are insufficient and based on contradicting data. A study indicated that post-surgical cerebrovascular illness is a significant complication within 90 days of TJA in HIV-positive patients. Still, findings of another study showed cerebrovascular events to be highly unlikely after TJA in people with HIV infection.¹^,⁵ Similarly, studies pointed out that HIV patients show a notably higher number of wound and prosthetic infections after joint replacement surgery.¹ Contrary to this, findings of other studies yielded that prosthetic infection is an insignificant post-surgical complication.⁶

All these variations in the existing literature create ambiguity among physicians in understanding which complications they should be prepared to encounter.⁷ Therefore, to sort out discrepancies in the existing literature, we thoroughly reviewed and found no study that compiled all possible complications. Thus, we aim to conduct a meta-analysis that statistically analyzes all the post-surgical complications in HIV patients undergoing total joint arthroplasty.

2 Materials and METHODS

2.1

2.1 Data sources and search strategy

This Systematic review/Meta-analysis is conducted following Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. There is no need for ethical approval since it is a systematic review of already published data. An electronic search from PubMed/Medline, Cochrane Library, and Google Scholar was conducted from inception till May 1, 2023 with only English language-based literature using the search string: (HIV OR Human immunodeficiency virus OR AIDS) AND (Total joint OR Total knee OR Total hip OR Total shoulder OR Total ankle OR TJA OR TSA OR TKA OR TAA OR THA OR TJR OR THR OR TKR OR TSR) AND (replace∗ OR arthroplast∗). This systematic review was registered on PROSPERO # CRD42022348094.

2.2

2.2 Study selection

All studies were included, which met the following criteria described as PECOS (1) P (Population) Patients who underwent Primary Total Joint Arthroplasty (TJA) surgery⁸ Exposure: HIV infection/AIDs⁹ Control: Patients without HIV infection/AIDs (4) Outcome: Post-operative complications after arthroplasty in HIV/AIDs population (5) S (Studies): Retrospective studies, case-control studies, cohort studies and Randomized clinical trials published in English language only. The rest of the articles like case reports, case series, animal studies, editorials, other systematic reviews, and meta-analyses were excluded. Studies not meeting the inclusion criteria were excluded.

2.3

2.3 Data extraction and quality assessment of studies

Studies selected were exported to EndNote Reference Library software version x8.2 (Clarivate Analytics) and duplicates were screened and removed. Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of included cohort studies. NOS score <6 was considered a high risk of bias while NOS Score ≥6 is considered a low risk. To decide the appropriate time for follow-up, we considered median follow-up time. The study reporting follow-up time more than the median follow-up was given a (1) Score, and those reporting less follow-up time than the median follow-up were given a (0) score. Publication bias will be assessed through a funnel plot if at least ten studies report any outcome.

2.4

2.4 Statistical Analysis

Meta-analysis will be conducted by pooling odds ratios of all studies reporting the impact of AIDs/HIV infection on postoperative complications following total joint arthroplasty. The pooled result will be computed as OR/HR with a 95 % confidence interval using the fixed-effects model. OR/HR with 95%CI will be extracted from multivariate Analysis of original studies only. Data from OR and HR will be analyzed separately since they can't be pooled together. The study heterogeneity will be quantified and assessed using Cochran's Q test and I² statistics. A random-effects model will be used.

3 RESULTS

3.1

3.1 Literature search

The initial literature search yielded 927 articles. After de-duplication, 649 were screened. These articles were screened by reading the title/abstract and 113 articles were selected for full-text screening. At last, 16 articles were included in the meta-analysis⁵^,⁶^,^10–23 (Fig. 1).

3.2

3.2 Study characteristics

A total of 17,974,549 patients were included in our review. All 16 studies included in our Analysis were retrospective cohort studies. Out of these, THA was evaluated by 11 studies,⁵^,⁶^,^11–14^,¹⁶^,¹⁸^,¹⁹^,²¹^,²² and TKA was reviewed by 11 studies,⁵^,⁶^,¹⁰^,¹¹^,^13–15^,^19–21^,²³ TSA was evaluated by two studies⁶^,¹⁷ and RTSA ¹⁷ was evaluated by 1 study. Different follow-up durations were observed in these studies. Three months follow-up was reported by three studies,⁵^,¹⁴^,¹⁷ 1-year follow-up was reported by two studies,¹¹^,²² 2-year follow-up was reported by six studies,⁵^,⁶^,¹²^,¹⁷^,²¹^,²³ 4-year follow-up was reported by 1 study.¹⁹ Six studies reported a follow-up till the end of the study period¹⁰^,¹³^,¹⁵^,¹⁶^,¹⁸^,²⁰ (Table 1) (see Table 2).

Table 1 Basic study characteristics

Variable	Study design	Country	Total procedures/patients (n)	HIV patients (n)	HIV diagnosis	Type of arthroplasty	Type of complication	Follow-up	NOS score
Tornero et al., 2012	Retrospective cohort	Spain	40	13	HIV unit database	THA	Persistent joint pain, septic knee arthritis, osteonecrosis	Minimum 1 Year	7
Lin et al., 2014	Retrospective cohort	U. S	394	22	City-wide clinical database of HIV + patients within the hospital network	THA, TKA	PJI, Revision arthroplasty	Minimum 2 years	6
Boylan et al., 2015	Retrospective cohort	U. S	5,675,086	2772	ICD-9	TKA	Perioperative Wound infection, osteonecrosis, deep chronic infection, chronic osteomyelitis	Till the end of the study period	8
Menendez et al., 2015	Retrospective cohort	U. S	3,096,791	N/A	ICD-9	THA, TKA	Myocardial infarction,	4 years	8
Naziri et al., 2015	Retrospective Cohort	U. S	2,665,971	9275	ICD-9	THA	Acute renal failure, pneumonia, wound hemorrhage, osteonecrosis	Till the end of the study period	8
Bala et al., 2016	Retrospective cohort	U. S	145,761	2528	ICD-9, CPT	TSA, RTSA	Acute renal failure, Anemia, MI, DVT, Sepsis, Respiratory failure, Heart failure, Stroke/CVA, Pneumonia, broken prosthetic joints, Dislocations of joints, Periprosthetic infections, revision and repair, Closed proximal humerus fractures	Surgical: Minimum 2 YearsMedical: 3 months	6
Mahure et al., 2017	Retrospective cohort	U. S	80,722	534	ICD-9	THA	DVT, Hematoma/seroma, Peripheral vascular complications, Postoperative Delirium, Pulmonary complications	Till the end of the study period	8
Salt et al., 2017	Retrospective cohort	U. S	2212	9	ICD-9	THA, TKA, TSA	Post-operative infection	2 years	8
Kildow et al., 2018	Retrospective cohort	U. S	22,663	1517	ICD-9, CPT	THA, TKA	DVT, Transfusion, Joint loosening, periprosthetic fracture and revision arthroplasty, PJI And I&D	Medical: 3 monthsSugicial:2 years	6
Mistry et al., 2018	Retrospective cohort	U. S	3,108,057	N/A	ICD-9	TKA	Allogenic transfusion	Till the end of the study period	8
Edmiston et al., 2019	Retrospective cohort	U. S	498,681	49,868	ICD-9, CPT	THA, TKA	Surgical site infections, revision surgery,	3 months	8
Chen et al., 2021	Retrospective cohort	U. S	1,821,752	N/A	ICD-9	THA, TKA	Heparin-induced thrombocytopenia	Till the end of the study period	8
Ngwasi et al., 2021	Retrospective cohort	South Africa	290	180	Patient notes	THA	Periprosthetic joint infection, Venous thromboembolism, Reoperation	Minimum 2 years	8
Olson et al., 2022	Retrospective cohort	U. S	350	110	Coding data from three tertiary referral academic institution	THA, TKA	Venous thromboembolism	Minimum 1 year	6
Sakthivelnathan et al., 2022	Retrospective cohort	U. S	406	203	ICD-10	TKA	Acute renal failure, Blood loss anemia, PE, DVT, Pneumonia, Periprosthetic fracture, Periprosthetic dislocations, mechanical complications, Wound dehiscence, Blood transfusions	Till the end of the study period	6
Elzomor et al., 2022	Retrospective Cohort	U. S	855, 373	1606	ICD-9, ICD-10	TKA	Revision, PJI, Loosening, Movement under anesthesia, SSI, renal failure, anemia, arrhythmia, bleeding, blood transfusion, pneumonia, stroke, death, venous thromboembolism, respiratory complication, sepsis	2 years	8

Table 2 COMPLICATIONS due to HIV IN TOTAL JOINT ARTHROPLASTY.

COMPLICATIONS	NO. OF STUDIES	ODDS RATIO [95 % CONFIDENCE INTERVAL]	P-VALUE	HETEROGENEITY
INFECTIOUS COMPLICATIONS
Prosthetic joint infection	7 [5, 6, 10, 12, 17, 21, 23]	1.79 [1.35, 2.36]	p < 0.00001	36 %
Wound infections	4 [14, 18, 20, 23]	1.91 [1.14, 3.19]	p = 0.01	71 %
Sepsis/SIRS	3 [5, 17, 23]	1.75 [0.84, 3.67]	p = 0.14	85 %
Urinary tract infections	1 17	2.01 [1.70, 2.38]	p < 0.00001	N/A
Overall	10 [5, 6, 10, 12, 14, 17, 18, 20, 21, 23]	1.82 [1.49, 2.22]	p < 0.00001	62 %
MEDICAL COMPLICATIONS
Blood transfusion	7 [5, 10, 15–17, 22, 23]	1.61 [1.18, 2.20]	p = 0.003	87 %
Venous thromboembolism	6 [5, 10–12, 17, 23]	1.37 [1.02, 1.84]	p = 0.03	60 %
Acute renal disease	5 [5, 10, 17, 18, 23]	1.68 [1.22, 2.31]	p = 0.001	73 %
Pneumonia	5 [5, 10, 17, 18, 23]	1.59 [1.11, 2.28]	p = 0.01	71 %
Myocardial infarction	3 [5, 17, 19]	2.56 [0.91, 7.21]	p = 0.08	94 %
Stroke/CVA	2 [5, 17]	7.16 [0.19, 265.26]	p = 0.29	99 %
Anemia	3 [10, 17, 23]	1.24 [0.79, 1.97]	p = 0.35	94 %
Respiratory failure	1 17	3.20 [2.20, 4.66]	p < 0.00001	N/A
Heart failure	2 [17, 23]	1.49 [0.58, 3.84]	p = 0.41	97 %
Arrhythmias	2 [17, 23]	1.30 [0.52, 3.23]	p = 0.57	98 %
Heparin-induced thrombocytopenia	1 13	5.86 [1.27, 27.04]	p = 0.02	N/A
Delirium	1 16	2.91 [2.67, 3.17]	p < 0.00001	N/A
Unspecified medical complications	1 20	1.13 [0.73, 1.75]	p = 0.58	N/A
Overall	13 [5, 10–13, 15–20, 22, 23]	1.85 [1.41, 2.42]	p < 0.00001	82.8 %
SURGICAL COMPLICATIONS
Revision surgery	4 [5, 17, 21, 23]	1.95 [0.89, 4.26]	P = 0.09	91 %
Periprosthetic fractures	3 [5, 10, 17]	1.95 [1.40, 2.72]	p < 0.0001	0 %
Mechanical complications	3 [5, 10, 17]	1.44 [0.82, 2.53]	p = 0.21	87 %
Joint dislocations	2 [10, 17]	1.58 [1.19, 2.09]	p = 0.002	0 %
Prosthetic loosening	2 [5, 23]	1.04 [0.71,1.55]	P = 0.83	0 %
Joint instability	2 [5, 17]	1.07 [0.76, 1.51]	p = 0.70	0 %
Manipulation under anesthesia	3 [5, 17, 23]	1.43 [1.06, 1.94]	p = 0.02	56 %
Post-operative bleeding	2 [17, 18]	1.88 [1.42, 2.49]	p < 0.0001	3 %
Joint stiffness	2 [5, 17]	1.17 [1.02, 1.35]	p = 0.03	66 %
Incision & drainage	2 [5, 17]	1.63 [1.34, 1.98]	p < 0.00001	59 %
Wound dehiscence	1 10	1.00 [0.06, 16.13]	p = 1.00	N/A
Cellulitis/Seroma	1 17	4.12 [2.35, 7.22]	p < 0.00001	N/A
Joint pain	1 17	1.82 [1.63, 2.03]	p < 0.00001	N/A
Reoperation	1 12	1.22 [0.11, 13.53]	P = 0.87	N/A
Unspecified surgical complications	1 20	1.50 [0.80, 2.81]	p = 0.21	N/A
Overall	8 [5, 10, 12, 17, 18, 20, 21, 23]	1.58 [1.38, 1.82]	p < 0.00001	76 %
GENERAL COMPLICATIONS
Readmission	1 16	2.52 [2.09, 3.04]	p < 0.00001	N/A
Extended length of stay	1 16	1.88 [1.51, 2.34]	p < 0.00001	N/A
Overall	1 16	2.19 [1.64, 2.92]	p < 0.00001	74.8 %

3.3

3.3 Quality assessment and publication bias

The quality of individual studies was determined through the NOS scale. All studies have a low risk of bias (median = 8) (Table 1). There was no publication bias since the funnel plot appeared symmetrical on visual inspection (Fig. 2).

3.4

3.4 Complications due to HIV in patients undergoing TJA

3.4.1

3.4.1 Infectious COMPLICATIONS

Infectious complications were reported in 10 studies.⁵^,⁶^,¹⁰^,¹²^,¹⁴^,¹⁷^,¹⁸^,²⁰^,²¹^,²³ Overall HIV infected patients were at significant risk of developing infectious complications (OR 1.82 [1.49, 2.22]; p < 0.00001; I² = 62 %.

The relationship between HIV infection and individual infectious complications was also evaluated. Prosthetic joint infection (PJI) was reported in 7 studies.⁵^,⁶^,¹⁰^,¹²^,¹⁷^,²¹^,²³ HIV-infected patients undergoing TJA were at significant risk of developing PJI (OR 1.79 [1.35, 2.36]; p < 0.00001; I² = 36 %). Wound infection was reported in 4 studies¹⁴^,¹⁸^,²⁰^,²³ and was a significant complication in HIV-infected patients (OR 1.91 [1.14, 3.19]; p = 0.01; I² = 71 %). Sepsis/Systemic inflammatory response syndrome (SIRS) was reported by three studies⁵^,¹⁷^,²³ and was an insignificant complication in HIV-infected patients (OR 1.75 [0.84, 3.67]; p = 0.14; I² = 85 %). Similarly, urinary tract infection was reported by 1 study¹⁷ and was also a significant complication of HIV following TJA (OR 2.01 [1.70, 2.38]; p < 0.00001) (Table 3).

Table 3 Subgroup analysis of COMPLICATIONS based on ARTHROPLASTY type.

COMPLICATIONS	NO. OF STUDIES	OR [95 % Confidence Interval]	p-value
TKA
Infectious Complications	6 [5, 10, 14, 20, 21, 23]	1.67 [1.19, 2.34]	P = 0.003
Medical Complications	6 [5, 10, 13, 15, 20, 23]	1.24 [1.03, 1.48]	p = 0.02
Surgical Complications	5 [5, 10, 20, 21, 23]	1.35 [1.09, 1.67]	p = 0.007
THA
Infectious Complications	3 [5, 18, 21]	1.76 [1.26, 2.46]	p = 0.001
Medical Complications	6 [5, 11, 12, 16, 18, 22]	1.54 [1.12, 2.12]	p = 0.001
Surgical Complications	4 [5, 12, 18, 21]	1.50 [1.22, 1.86]	p = 0.0002
General Complications	1 16	2.19 [1.64, 2.92]	p < 0.00001

3.4.2

3.4.2 Medical COMPLICATIONS

Medical complications due to HIV following TJA were reported by 13 studies.⁵^,^10–13^,^15–20^,²²^,²³ Overall HIV infected patients were at a significantly higher risk of developing medical complications after TJA (OR 1.85 [1.41, 2.42]; p < 0.00001; I² = 82.8 %).

The risk of individual medical complications following TJA was also assessed. Seven studies⁵^,¹⁰^,^15–17^,²²^,²³ reported a significant relationship between HIV infection and post-operative blood transfusion (OR 1.61 [1.18, 2.20]; p = 0.003; I² = 87 %). 6 studies⁵^,^10–12^,¹⁷^,²³ reported a significant risk of venous thromboembolism due to HIV following TJA (OR 1.37 [1.02, 1.84]; p = 0.03; I² = 60 %). 5 studies⁵^,¹⁰^,¹⁷^,¹⁸^,²³ reported significant risk of HIV in causing acute renal disease (OR 1.68 [1.22, 2.31]; p = 0.001; I² = 73 %). Five studies⁵^,¹⁰^,¹⁷^,¹⁸^,²³ reported a significant impact of HIV in causing pneumonia after TJA (OR 1.59 [1.11, 2.28]; p = 0.01; I² = 71 %). Three studies⁵^,¹⁷^,¹⁹ reported a non-significant association between HIV and myocardial infarction following TJA (OR 2.56 [0.91, 7.21]; p = 0.08; I² = 94 %). 2 studies⁵^,¹⁷ found that HIV infection is not a significant risk factor for causing stroke/cerebrovascular accidents (OR 7.16 [0.19, 265.26]; p = 0.29; I² = 99 %). Three studies⁵^,¹⁰^,²³ reported an insignificant relationship between HIV infection and anemia (OR 1.24 [0.79, 1.97]; p = 0.35; I² = 94 %). 1 study reported respiratory failure as a complication following TJA (OR 3.20 [2.20, 4.66]: p < 0.00001).¹⁷ 2 study reported heart failure as a complication following TJA (OR 1.49 [0.58, 3.84]; p = 0.41; I² = 97 %).¹⁷ 2 study¹⁷^,²³ reported arrhythmias which was not a significant complication following TJA (OR 1.30 [0.52, 3.23]; p = 0.57; I² = 98 %). 1 study¹³ explored the relationship between HIV and the development of heparin-induced thrombocytopenia (OR 5.86 [1.27, 27.04]; p = 0.02). 1 study¹⁶ discovered the adverse impact of HIV on the development of delirium (OR 2.91 [2.67, 3.17]; p < 0.00001). 1 study²⁰ reported unspecified medical complications following TJA (OR 1.13 [0.73, 1.75]; p < 0.00001).

3.4.3

3.4.3 SURGICAL COMPLICATIONS

Surgical complications due to HIV following TJA were reported by eight studies.⁵^,¹⁰^,¹²^,¹⁷^,¹⁸^,²⁰^,²¹^,²³ Overall HIV patients were at a significantly higher risk of developing surgical complications following TJA (OR 1.58 [1.38, 1.82]; p < 0.00001; I² = 76 %).

The risk of individual surgical complications was also studied. Four studies⁵^,¹⁷^,²¹^,²³ evaluated the risk of revision surgery in HIV patients following TJA, and it was found to be insignificant (OR 2.95 [0.89, 4.26]; p = 0.09; I² = 91 %). Three studies⁵^,¹⁰^,¹⁷ found that there was an increased risk of peri-prosthetic fractures if an HIV-infected patient underwent TJA (OR 1.95 [1.40, 2.72]; p < 0.0001; I² = 0 %). Three studies⁵^,¹⁰^,¹⁷ reported that HIV is a significant risk factor for mechanical complications (OR 1.85 [1.56, 2.21]; p < 0.00001; I² = 87 %). 2 studies¹⁰^,¹⁷ described joint dislocations as a complication due to pre-operative HIV infection (OR 1.58 [1.19, 2.09]; p = 0.002; I² = 0 %). 2 studies⁵^,¹⁷ showed that HIV infection is not a significant risk factor for joint instability following TJA (OR 1.07 [0.76, 1.51]; p = 0.70; I² = 0 %). Three studies⁵^,¹⁷^,²³ reported a significant risk of HIV patients undergoing post-operative manipulation under anesthesia (OR 1.43 [1.06, 1.94]; p = 0.02; I² = 56 %). 2 studies¹⁷^,¹⁸ reported a significant risk of postoperative bleeding in HIV infected patients undergoing TJA (OR 1.88 [1.42, 2.49]; p < 0.0001; I² = 3 %). 2 studies⁵^,¹⁷ reported that HIV infected patients were at significant risk for undergoing incision and drainage following TJA (OR 1.63 [1.34, 1.98]; p < 0.00001; I² = 59 %). 2 studies⁵^,¹⁷ showed that HIV infected patients were at significantly increased risk for developing joint stiffness after TJA (OR 1.17 [1.02, 1.35]; I² = 66 %; p = 0.03). 1 study¹⁰ reported that HIV patients were not at significant risk for wound dehiscence following TJA (OR 1.00 [0.06, 16.13]; p = 1.00). 1 study¹⁰ reported cellulitis/seroma as a significant complication following TJA (OR 4.12 [2.35, 7.22]; p < 0.00001). 1 study¹⁷ reported HIV infection as a significant risk factor for post-operative joint pain (OR 1.82 [1.63, 2.03]; p < 0.00001). 1 study¹² reported that HIV does not increase the risk of reoperation following TJA (OR 1.22 [0.11, 13.53]; p = 0.87), and 1 study²⁰ reported the risk of unspecified surgical complications following TJA (OR 1.50 [0.80, 2.81]); p = 0.21). Prosthetic loosening was reported by two studies,⁵^,²³ and it was an insignificant complication following TJA (OR 1.04 [0.71, 1.55]; p = 0.83; I² = 0 %).

3.4.4

3.4.4 General COMPLICATIONS

General complications following TJA were reported by 1 study¹⁶ (OR 2.19 [1.64, 2.92]; p < 0.00001; I² = 74.8 %).

Individual general complications include readmission and extended length of stay following TJA. 1 study¹⁶ reported HIV infection as a significant risk for readmission following TJA (OR 2.52 [2.09, 3.04]; p < 0.00001). Similarly, 1 study¹⁶ reported HIV infection as a significant risk for an extended length of stay (OR 1.88 [1.51, 2.34]; p < 0.00001).

3.5

3.5 Subgroup analysis based on arthroplasty type

We performed subgroup analysis based on the type of arthroplasty. Complications due to HIV were assessed in THA and TKA. Since there was only one study on TSA we could not perform separate subgroup analyses.

3.5.1

3.5.1 TKA

Infectious complications were reported in 6 studies.⁵^,¹⁰^,¹⁴^,²⁰^,²¹^,²³ Patients were at significantly higher risk of infectious complications following TKA (OR 1.67 [1.19, 2.34]; p = 0.003; I² = 70 %). Medical complications were reported in 6 studies⁵^,¹⁰^,¹⁵^,²³ and were significantly associated with HIV-infected patients undergoing TKA (OR 1.24 [1.03, 1.48]; p = 0.02; I² = 79 %). Surgical complications were reported in 5 studies⁵^,¹⁰^,²⁰^,²¹^,²³ and were significantly associated with HIV-infected patients undergoing TKA (OR 1.35 [1.09, 1.67]; p = 0.007; I² = 69 %).

3.5.2

3.5.2 THA

Infectious complications were reported in 3 studies.⁵^,¹⁸^,²¹ Patients were at significantly higher risk of infectious complications following THA (OR 1.76 [1.26, 2.46]; p = 0.0001; I² = 0 %). Medical complications were reported in 6 studies⁵^,¹¹^,¹²^,¹⁶^,¹⁸^,²² and were significantly associated with HIV-infected patients undergoing THA (OR 1.54 [1.12, 2.12; p = 0.007; I² = 85 %). Surgical complications were reported in 4 studies⁵^,¹²^,¹⁸^,²¹ and were significantly associated with HIV-infected patients undergoing THA (OR 1.50 [1.22, 1.86]; p = 0.0002; I² = 0 %). General complications were reported by 1 study¹⁶ and were significantly associated with HIV-infected patients following THA (OR 2.23 [1.93, 2.57]; p < 0.00001; I² = 75 %).

4 Discussion

A total of 19 studies analyzed in this systematic review and meta-analysis showed that pre-operative HIV infection is significantly related to an increased number of complications after TJA.⁵^,⁶^,^10–23 The principal findings were that patients with HIV undergoing TJA are prone to develop infectious complications, including prosthetic joint infection, wound infection, sepsis, and UTIs [ 5,6, 10, 12, 14, 17,18, 20,21, 23]. There was a significant risk of developing medical complications such as the need for post-operative blood transfusion, venous thromboembolism, pneumonia, anemia, delirium, arrhythmia, heparin-induced thrombocytopenia, and acute renal, respiratory, and heart failure.⁵^,^10–13^,^15–20^,²²^,²³

Our study also yielded that HIV-infected patients present a significant risk of surgical complications, including revision surgery, bleeding, joint stiffness, dislocation, pain, mechanical issues, cellulitis, manipulation under anesthesia, post-operative bleeding, incision & drainage, and periprosthetic fractures. Readmission and increased length of stay were also significantly experienced in HIV-infected patients.

HIV-infected patients are subjected to several complications after TJA. Periprosthetic joint infection (PJI) and wound infection are one of the significant threatening complications responsible for increased mortality rates and revision surgeries.²⁵ According to our study, HIV-infected TJA patients are at twice the risk of developing PJI and more than twice the risk of wound infection. A possible reason for this could be the increased rate of infections in HIV patients due to weakened immune systems.²⁴ A decrease in the count of CD4⁺ T cells is directly related to the incidence of peri-prosthetic joint infection.²⁵ As highlighted by Parvizi et al., 62.5 % of patients with a pre-operative CD4 count of less than 0.2 x10⁹/L³ experienced post-operative prosthetic joint and wound infections.²⁵

Aside from this, we also found a significantly increased number of transfusion rates in HIV patients undergoing TJA. Since such patients' reduced bone marrow function can result in clinically severe cytopenias, they require additional hematological support to get through the surgery.²⁶ This finding was in contradiction with Chowdary et al., which reported a lower rate of blood transfusion in HIV positive cohort.²⁷ Despite this, anemia was still significant in HIV-infected patients, seen in nearly 40 % of patients.²⁷^,²⁸ This supports the finding of our study in which anemia was also a significant complication in HIV-infected patients after total joint arthroplasty.

We also found that HIV-positive patients appeared to be more susceptible to venous thromboembolism. It has been shown that the combination of maximum flexion with either internal or external rotation causes femoral vein obstruction, which makes total hip arthroplasty (THA) mechanically pro-thrombotic.²⁹ Increasing viral load and decreasing CD4 count in HIV patients predisposes them to hypercoagulable state.³⁰^,³¹ As the disease progresses and the immune gets depressed, it results in an imbalance between pro and anti-coagulants.³⁰^,³¹ Therefore, HIV infection accounts for a significant independent risk factor of post-TJA venous thromboembolism with odds of 1.37.

Similarly, there was a marked increase in mechanical complications among HIV-positive patients following TJA. According to Labek et al., there was a 12 % rate of significant complications in HIV patients requiring revision surgery.³² These patients show increased avascular necrosis and opportunistic infection due to reduced CD4 count.³² This greatly contributes to exaggerated post-operative complications, requiring extended hospital stays and revision surgeries.³²^,³³

Taking proper pre-operative measures can reduce these complications. Smoking, obesity, anemia, rheumatoid arthritis, diabetes mellitus, and malnutrition are all modifiable risk factors that could be evaluated and managed pre-operatively.³⁴ Cemented stem fixation is one of the most effective prophylactic strategies for periprosthetic femur fractures.²⁹ Venous Thromboembolism can be assessed and safely managed by using prophylactic agents like aspirin for low-risk patients and enoxaparin or warfarin for higher-risk patients.²⁹ After the emergence of effective pharmacological medications, such as antiretroviral therapy (HAART), HIV has evolved into a treatable and controllable illness. Recent studies show that antiretroviral therapy given pre-operatively reduces the risk of complications post-operatively in these patients.²⁷^,²⁸

Earlier studies and reviews qualitatively addressed post-operative complications among HIV patients undergoing TJA. We are the first to quantify these complications instead of describing them generically.²⁴^,²⁷^,²⁸^,³⁰ Also, we are the only study to analyze these complications further based on the type of arthroplasty. However, our study has some limitations. Firstly, the data we used for this meta-analysis were taken from retrospective studies. Secondly, the sample size in some studies we used was small, considering the low prevalence of HIV in those areas. Thirdly, due to the unavailability of data, we couldn't study the variations in the result due to the diagnostic techniques, the duration of follow-up, and the stage of the disease. Finally, it's possible that some of the patients in our research were already taking antiretroviral therapy, so we could not distinguish them independently.

5 Conclusion

This in-depth review and meta-analysis of the existing evidence revealed that in total joint arthroplasty, HIV is highly associated with an increased rate of mechanical, surgical, and infectious complications as compared to non-HIV patients. These results can aid surgeons in managing the patients more effectively for the potential risk factors.

CRediT authorship contribution statement

Ramish Sumbal: Conceptualization, Supervision, Writing – original draft, Writing – review & editing. Saad Ashraf: Writing – original draft, Writing – review & editing. Anusha Sumbal: Supervision, Writing – original draft, Writing – review & editing. Uooja Devi: Project administration, Conceptualization, Writing – original draft, Writing – review & editing. Md Ariful Haque: Project administration, Writing – review & editing.

Ethics approval statement

This type of article doesn't need any ethical approval.

Funding statement

Authors have not received any funds.

References

Bala A., et al . Total shoulder arthroplasty in patients with HIV infection: complications, comorbidities, and trends. J Shoulder Elbow Surg. 2016;25(12):1971-1979.
[Google Scholar]
Lin C.A., et al . Mid-Term outcomes in HIV-positive patients after primary total hip or knee arthroplasty. J Arthroplasty. 2014;29(2):277-282.
[Google Scholar]
Lin C.A., Kuo A.C., Takemoto S., . Comorbidities and perioperative complications in HIV-positive patients undergoing primary total hip and knee arthroplasty. JBJS. 2013;95(11):1028-1036.
[Google Scholar]
Kong L., et al . Risk factors for periprosthetic joint infection following primary total hip or knee arthroplasty: a meta-analysis. Int Wound J. 2017;14(3):529-536.
[Google Scholar]
Kildow B.J., et al . Short and long-term postoperative complications following total joint arthroplasty in patients with human immunodeficiency virus, hepatitis B, or hepatitis C. J Arthroplasty. 2018;33(7s):S86-S92.e1.
[Google Scholar]
Salt E., et al . Moderating effects of immunosuppressive medications and risk factors for post-operative joint infection following total joint arthroplasty in patients with rheumatoid arthritis or osteoarthritis. Semin Arthritis Rheum. 2017;46(4):423-429.
[Google Scholar]
Sakthivelnathan V., et al . HIV/AIDS patients undergoing total knee arthroplasty are at higher risk of acute renal failure and transfusion and incurred higher cost: a propensity-matched database study. Knee Surgery & Related Research. 2022;34(1):28.
[Google Scholar]
Hecht C.J., et al . What is the association between clinically diagnosed psychiatric illness and total joint arthroplasty? A systematic review evaluating outcomes, healthcare use, and patient-reported outcome measures. Clin Orthop Relat Res. 2023;481(5):947-964.
[Google Scholar]
Hasenauer M.D., et al . Factors associated with the incidence and timing of total knee arthroplasty infection. J Arthroplasty. 2022;37(6s):S276-S280.e3.
[Google Scholar]
Sakthivelnathan V., et al . HIV/AIDS patients undergoing total knee arthroplasty are at higher risk of acute renal failure and transfusion and incurred higher cost: a propensity-matched database study. Knee Surg Relat Res. 2022;34(1):28.
[Google Scholar]
Olson J.J., et al . HIV-positive patients are at increased risk of venous thromboembolism after total joint replacement. J Am Acad Orthop Surg. 2021;29(11):479-485.
[Google Scholar]
Ngwazi M., et al . The association between HIV infection and periprosthetic joint infection following total hip replacement in young adults. South African Orthopaedic Journal. 2021;20(2):76-80.
[Google Scholar]
Chen Y., et al . Incidence, outcomes and risk factors of heparin-induced thrombocytopenia after total joint arthroplasty: a national inpatient sample database study. Clin Appl Thromb Hemost. 2021;27
[Google Scholar]
Edmiston C.E., et al . Impact of patient comorbidities on surgical site infection within 90 days of primary and revision joint (hip and knee) replacement. Am J Infect Control. 2019;47(10):1225-1232.
[Google Scholar]
Mistry J.B., et al . Are allogeneic transfusions decreasing in total knee arthroplasty patients? National inpatient sample 2009-2013. J Arthroplasty. 2018;33(6):1705-1712.
[Google Scholar]
Mahure S.A., et al . Risk of complications after THA increases among patients who are coinfected with HIV and hepatitis C. Clin Orthop Relat Res. 2018;476(2):356-369.
[Google Scholar]
Bala A., et al . Total shoulder arthroplasty in patients with HIV infection: complications, comorbidities, and trends. J Shoulder Elbow Surg. 2016;25(12):1971-1979.
[Google Scholar]
Naziri Q., et al . Does HIV infection increase the risk of perioperative complications after THA? A nationwide database study. Clin Orthop Relat Res. 2015;473(2):581-586.
[Google Scholar]
Menendez M.E., et al . A nationwide analysis of risk factors for in-hospital myocardial infarction after total joint arthroplasty. Int Orthop. 2015;39(4):777-786.
[Google Scholar]
Boylan M.R., et al . Does HIV infection increase the risk of short-term adverse outcomes following total knee arthroplasty? J Arthroplasty. 2015;30(9):1629-1632.
[Google Scholar]
Lin C.A., et al . Mid-term outcomes in HIV-positive patients after primary total hip or knee arthroplasty. J Arthroplasty. 2014;29(2):277-282.
[Google Scholar]
Tornero E., et al . Total hip arthroplasty in HIV-infected patients: a retrospective, controlled study. HIV Med. 2012;13(10):623-629.
[Google Scholar]
Elzomor A., et al . Human immunodeficiency virus status does not independently predict 2-year complications following total knee arthroplasty. J Knee Surg 2022
[Google Scholar]
Falakassa J., Diaz A., Schneiderbauer M., . Outcomes of total joint arthroplasty in HIV patients. Iowa Orthop J. 2014;34:102-106.
[Google Scholar]
Parvizi J., et al . Total joint arthroplasty in human immunodeficiency virus-positive patients: an alarming rate of early failure. J Arthroplasty. 2003;18(3):259-264.
[Google Scholar]
van den Berg K., et al . A review of the use of blood and blood products in HIV-infected patients. South Afr J HIV Med. 2012;13(2):87-104.
[Google Scholar]
Chowdary A.R., et al . Analysis of inpatient complications in HIV/AIDS patients undergoing total hip arthroplasty – a propensity matched cohort study. Journal of Clinical Orthopaedics and Trauma. 2023;40
[Google Scholar]
Cao G., et al . Prevalence of anemia among people living with HIV: a systematic review and meta-analysis. EClinicalMedicine. 2022;44
[Google Scholar]
Fontalis A., et al . Prevention of early complications following total hip replacement. Sicot j. 2021;7:61.
[Google Scholar]
Abgueguen P., et al . Vascular thrombosis and acute cytomegalovirus infection in immunocompetent patients: report of 2 cases and literature review. Clin Infect Dis. 2003;36(11):E134-E139.
[Google Scholar]
Bibas M., Biava G., Antinori A., . HIV-associated venous thromboembolism. Mediterr J Hematol Infect Dis. 2011;3(1)
[Google Scholar]
Labek G., et al . Revision rates after total joint replacement: cumulative results from worldwide joint register datasets. J Bone Jt Surg Br Vol. 2011;93(3):293-297.
[Google Scholar]
Jacob R., et al . Incidence of complications and revision surgery in HAART compliant HIV patients undergoing primary total hip and knee arthroplasty: an institutional review. Arch Orthop Trauma Surg. 2023;143(7):3803-3809.
[Google Scholar]
Scuderi G.R., . Avoiding postoperative wound complications in total joint arthroplasty. J Arthroplasty. 2018;33(10):3109-3112.
[Google Scholar]

Show Sections

[1] Bala A., et al . Total shoulder arthroplasty in patients with HIV infection: complications, comorbidities, and trends. J Shoulder Elbow Surg. 2016;25(12):1971-1979.
[Google Scholar]

[2] Lin C.A., et al . Mid-Term outcomes in HIV-positive patients after primary total hip or knee arthroplasty. J Arthroplasty. 2014;29(2):277-282.
[Google Scholar]

[3] Lin C.A., Kuo A.C., Takemoto S., . Comorbidities and perioperative complications in HIV-positive patients undergoing primary total hip and knee arthroplasty. JBJS. 2013;95(11):1028-1036.
[Google Scholar]

[4] Kong L., et al . Risk factors for periprosthetic joint infection following primary total hip or knee arthroplasty: a meta-analysis. Int Wound J. 2017;14(3):529-536.
[Google Scholar]

[5] Kildow B.J., et al . Short and long-term postoperative complications following total joint arthroplasty in patients with human immunodeficiency virus, hepatitis B, or hepatitis C. J Arthroplasty. 2018;33(7s):S86-S92.e1.
[Google Scholar]

[6] Salt E., et al . Moderating effects of immunosuppressive medications and risk factors for post-operative joint infection following total joint arthroplasty in patients with rheumatoid arthritis or osteoarthritis. Semin Arthritis Rheum. 2017;46(4):423-429.
[Google Scholar]

[7] Sakthivelnathan V., et al . HIV/AIDS patients undergoing total knee arthroplasty are at higher risk of acute renal failure and transfusion and incurred higher cost: a propensity-matched database study. Knee Surgery & Related Research. 2022;34(1):28.
[Google Scholar]

[8] Hecht C.J., et al . What is the association between clinically diagnosed psychiatric illness and total joint arthroplasty? A systematic review evaluating outcomes, healthcare use, and patient-reported outcome measures. Clin Orthop Relat Res. 2023;481(5):947-964.
[Google Scholar]

[9] Hasenauer M.D., et al . Factors associated with the incidence and timing of total knee arthroplasty infection. J Arthroplasty. 2022;37(6s):S276-S280.e3.
[Google Scholar]

[10] Sakthivelnathan V., et al . HIV/AIDS patients undergoing total knee arthroplasty are at higher risk of acute renal failure and transfusion and incurred higher cost: a propensity-matched database study. Knee Surg Relat Res. 2022;34(1):28.
[Google Scholar]

[11] Olson J.J., et al . HIV-positive patients are at increased risk of venous thromboembolism after total joint replacement. J Am Acad Orthop Surg. 2021;29(11):479-485.
[Google Scholar]

[12] Ngwazi M., et al . The association between HIV infection and periprosthetic joint infection following total hip replacement in young adults. South African Orthopaedic Journal. 2021;20(2):76-80.
[Google Scholar]

[13] Chen Y., et al . Incidence, outcomes and risk factors of heparin-induced thrombocytopenia after total joint arthroplasty: a national inpatient sample database study. Clin Appl Thromb Hemost. 2021;27
[Google Scholar]

[14] Edmiston C.E., et al . Impact of patient comorbidities on surgical site infection within 90 days of primary and revision joint (hip and knee) replacement. Am J Infect Control. 2019;47(10):1225-1232.
[Google Scholar]

[15] Mistry J.B., et al . Are allogeneic transfusions decreasing in total knee arthroplasty patients? National inpatient sample 2009-2013. J Arthroplasty. 2018;33(6):1705-1712.
[Google Scholar]

[16] Mahure S.A., et al . Risk of complications after THA increases among patients who are coinfected with HIV and hepatitis C. Clin Orthop Relat Res. 2018;476(2):356-369.
[Google Scholar]

[17] Bala A., et al . Total shoulder arthroplasty in patients with HIV infection: complications, comorbidities, and trends. J Shoulder Elbow Surg. 2016;25(12):1971-1979.
[Google Scholar]

[18] Naziri Q., et al . Does HIV infection increase the risk of perioperative complications after THA? A nationwide database study. Clin Orthop Relat Res. 2015;473(2):581-586.
[Google Scholar]

[19] Menendez M.E., et al . A nationwide analysis of risk factors for in-hospital myocardial infarction after total joint arthroplasty. Int Orthop. 2015;39(4):777-786.
[Google Scholar]

[20] Boylan M.R., et al . Does HIV infection increase the risk of short-term adverse outcomes following total knee arthroplasty? J Arthroplasty. 2015;30(9):1629-1632.
[Google Scholar]

[21] Lin C.A., et al . Mid-term outcomes in HIV-positive patients after primary total hip or knee arthroplasty. J Arthroplasty. 2014;29(2):277-282.
[Google Scholar]

[22] Tornero E., et al . Total hip arthroplasty in HIV-infected patients: a retrospective, controlled study. HIV Med. 2012;13(10):623-629.
[Google Scholar]

[23] Elzomor A., et al . Human immunodeficiency virus status does not independently predict 2-year complications following total knee arthroplasty. J Knee Surg 2022
[Google Scholar]

[24] Falakassa J., Diaz A., Schneiderbauer M., . Outcomes of total joint arthroplasty in HIV patients. Iowa Orthop J. 2014;34:102-106.
[Google Scholar]

[25] Parvizi J., et al . Total joint arthroplasty in human immunodeficiency virus-positive patients: an alarming rate of early failure. J Arthroplasty. 2003;18(3):259-264.
[Google Scholar]

[26] van den Berg K., et al . A review of the use of blood and blood products in HIV-infected patients. South Afr J HIV Med. 2012;13(2):87-104.
[Google Scholar]

[27] Chowdary A.R., et al . Analysis of inpatient complications in HIV/AIDS patients undergoing total hip arthroplasty – a propensity matched cohort study. Journal of Clinical Orthopaedics and Trauma. 2023;40
[Google Scholar]

[28] Cao G., et al . Prevalence of anemia among people living with HIV: a systematic review and meta-analysis. EClinicalMedicine. 2022;44
[Google Scholar]

[29] Fontalis A., et al . Prevention of early complications following total hip replacement. Sicot j. 2021;7:61.
[Google Scholar]

[30] Abgueguen P., et al . Vascular thrombosis and acute cytomegalovirus infection in immunocompetent patients: report of 2 cases and literature review. Clin Infect Dis. 2003;36(11):E134-E139.
[Google Scholar]

[31] Bibas M., Biava G., Antinori A., . HIV-associated venous thromboembolism. Mediterr J Hematol Infect Dis. 2011;3(1)
[Google Scholar]

[32] Labek G., et al . Revision rates after total joint replacement: cumulative results from worldwide joint register datasets. J Bone Jt Surg Br Vol. 2011;93(3):293-297.
[Google Scholar]

[33] Jacob R., et al . Incidence of complications and revision surgery in HAART compliant HIV patients undergoing primary total hip and knee arthroplasty: an institutional review. Arch Orthop Trauma Surg. 2023;143(7):3803-3809.
[Google Scholar]

[34] Scuderi G.R., . Avoiding postoperative wound complications in total joint arthroplasty. J Arthroplasty. 2018;33(10):3109-3112.
[Google Scholar]

Complications due to HIV in patients undergoing total joint arthroplasty: A systematic review and meta-analysis

Abstract