Correspondence Osteonecrosis of the Femoral Head: Evaluation and Treatment
Dr. van der Jagt or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of and serves as a paid consultant to Boehringer Ingelheim, and serves as a board member, owner, officer, or committee member of the South African Orthopaedic Association and the South African Society for Thrombosis and Haemostatis. Dr. Mokete or an immediate family member has received research or institutional support from Biomet and Smith & Nephew. Dr. Lieberman or an immediate family member has received royalties from DePuy; serves as a paid consultant to Arthrex and DePuy; has stock or stock options held in Hip Innovation Technology; has received research or institutional support from Arthrex; and serves as board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Pietrzak and Dr. Zalavras. http://dx.doi.org/10.5435/ JAAOS-D-14-00431
To the Editor: We would like to commend Drs. Zalavras and Lieberman for their excellent review article on osteonecrosis of the hip.1 We do need, however, to highlight the massive disease burden that many less developed parts of the world are subjected to as a consequence of HIV and its management. The high incidence of osteonecrosis of the hip as a result of HIV infection is well documented.2,3 In the past, the limited lifespan of these patients meant that the orthopaedic management load was limited. The introduction of effective disease control measures, especially anti-retroviral therapy (ART), has resulted in these patients’ surviving relatively HIV-symptom free and with a near-normal life expectancy. This increased survivorship in respect of HIV infections, however, has allowed the disease-related sequela osteonecrosis to become common place. This is further compounded by the osteonecrosis’ resulting directly from the treatment with ART,4 in itself essential to keep the progression of HIV to AIDS at bay. At the Johannesburg, South Africa, Complex of Academic Hospitals, we have experienced a dramatic rise in osteonecrosis of the hip, usually in young people who are HIV positive and on ART. Fully 25% of all the hip replacements currently done at our hospitals for end-stage osteonecrosis are now due to HIV/ART. This additional burden on our stretched resources is over and above the routine demand for joint arthroplasties for degenerative and other joint disease. Actuarial calculations project that within 10 years, we may need to
perform more than an additional 1,000 hip replacements for HIV/ ART-related osteonecrosis at the Johannesburg Complex of Academic Hospitals alone.5 We are sure that the review by these authors1 would have been enhanced by some mention of HIV and ART in the etiology and pathogenesis of osteonecrosis of the hip. Dick van der Jagt, MBBch, FCS(SA) Orth Lipalo Mokete, MBBch, FCS(SA) Orth Jurek Pietrzak, MBBch, FCS(SA) Orth Johannesburg, South Africa The Authors Reply: We would like to thank Drs. van der Jagt, Mokete, and Pietrzak for finding our review excellent and for their important comment. We agree that there is an increased incidence of osteonecrosis in HIV-infected patients. As these authors report, the increased survivorship of these patients has led to an increased number of joint arthroplasty procedures and a considerable burden on available healthcare resources, especially in developing countries. However, a direct link between antiretroviral therapy (ART) and osteonecrosis in HIV-infected patients has not been established, and for this reason, we did not include this in the etiology and pathogenesis section. Several case-control studies evaluating risk factors for the development of osteonecrosis in HIVinfected patients have not shown an association with ART.2,3,6-9 Instead, they documented the significantly
February 2015, Vol 23, No 2
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
69
Correspondence
increased presence of already established risk factors, such as corticosteroid use,2,3,7,9 coagulopathy,3 hyperlipidemia,3,4 and alcohol consumption,9 in HIV-infected patients who developed osteonecrosis compared with HIV-infected patients who did not develop the disease. Our suspicion is that there is some type of association, but further study of this issue is needed to define it. Thank you again for highlighting the important problem of osteonecrosis in HIV-infected patients. A high index of suspicion for osteonecrosis in these patients may lead to diagnosis at an earlier stage and treatment with a femoral head-sparing procedure, thereby potentially decreasing the burden of the disease.
70
Charalampos G. Zalavras, MD Jay R. Lieberman, MD Los Angeles, CA
5. Mokete L, Mohideen M, Pietrzak JR, van der Jagt DR: Projections for elective total hip replacement for osteonecrosis of the hip in HIV: is South Africa adequately prepared? Bloemfontein, South Africa, S Afr Orthop Congr, 2014, p 113. 6. Scribner AN, Troia-Cancio PV, Cox BA, et al: Osteonecrosis in HIV: A case-control study. J Acquir Immune Defic Syndr 2000;25(1):19-25.
References 1. Zalavras CG, Lieberman JR: Osteonecrosis of the femoral head: Evaluation and treatment. J Am Acad Orthop Surg 2014;22(7):455-464. 2. Keruly JC, Chaisson RE, Moore RD: Increasing incidence of avascular necrosis of the hip in HIV-infected patients. J Acquir Immune Defic Syndr 2001;28(1):101-102. 3. Miller KD, Masur H, Jones EC, et al: High prevalence of osteonecrosis of the femoral head in HIV-infected adults. Ann Intern Med 2002;137(1):17-25. 4. Matos MA, Alencar RW, Matos SS: Avascular necrosis of the femoral head in HIV infected patients. Braz J Infect Dis 2007;11(1):31-34.
7. Glesby MJ, Hoover DR, Vaamonde CM: Osteonecrosis in patients infected with human immunodeficiency virus: A case-control study. J Infect Dis 2001;184(4):519-523. 8. Hasse B, Ledergerber B, Egger M, et al; Swiss HIV Cohort Study: Antiretroviral treatment and osteonecrosis in patients of the Swiss HIV Cohort Study: A nested case-control study. AIDS Res Hum Retroviruses 2004;20(9):909-915. 9. Lawson-Ayayi S, Bonnet F, Bernardin E, et al; Groupe d’Epidémiologie Clinique du SIDA en Aquitaine: Avascular necrosis in HIV-infected patients: A case-control study from the Aquitaine Cohort, 1997-2002, France. Clin Infect Dis 2005;40(8):1188-1193.
Journal of the American Academy of Orthopaedic Surgeons
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Dr. van der Jagt or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of and serves as a paid consultant to Boehringer Ingelheim, and serves as a board member, owner, officer, or committee member of the South African Orthopaedic Association and the South African Society for Thrombosis and Haemostatis. Dr. Mokete or an immediate family member has received research or institutional support from Biomet and Smith & Nephew. Dr. Lieberman or an immediate family member has received royalties from DePuy; serves as a paid consultant to Arthrex and DePuy; has stock or stock options held in Hip Innovation Technology; has received research or institutional support from Arthrex; and serves as board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Pietrzak and Dr. Zalavras. http://dx.doi.org/10.5435/ JAAOS-D-14-00431
To the Editor: We would like to commend Drs. Zalavras and Lieberman for their excellent review article on osteonecrosis of the hip.1 We do need, however, to highlight the massive disease burden that many less developed parts of the world are subjected to as a consequence of HIV and its management. The high incidence of osteonecrosis of the hip as a result of HIV infection is well documented.2,3 In the past, the limited lifespan of these patients meant that the orthopaedic management load was limited. The introduction of effective disease control measures, especially anti-retroviral therapy (ART), has resulted in these patients’ surviving relatively HIV-symptom free and with a near-normal life expectancy. This increased survivorship in respect of HIV infections, however, has allowed the disease-related sequela osteonecrosis to become common place. This is further compounded by the osteonecrosis’ resulting directly from the treatment with ART,4 in itself essential to keep the progression of HIV to AIDS at bay. At the Johannesburg, South Africa, Complex of Academic Hospitals, we have experienced a dramatic rise in osteonecrosis of the hip, usually in young people who are HIV positive and on ART. Fully 25% of all the hip replacements currently done at our hospitals for end-stage osteonecrosis are now due to HIV/ART. This additional burden on our stretched resources is over and above the routine demand for joint arthroplasties for degenerative and other joint disease. Actuarial calculations project that within 10 years, we may need to
perform more than an additional 1,000 hip replacements for HIV/ ART-related osteonecrosis at the Johannesburg Complex of Academic Hospitals alone.5 We are sure that the review by these authors1 would have been enhanced by some mention of HIV and ART in the etiology and pathogenesis of osteonecrosis of the hip. Dick van der Jagt, MBBch, FCS(SA) Orth Lipalo Mokete, MBBch, FCS(SA) Orth Jurek Pietrzak, MBBch, FCS(SA) Orth Johannesburg, South Africa The Authors Reply: We would like to thank Drs. van der Jagt, Mokete, and Pietrzak for finding our review excellent and for their important comment. We agree that there is an increased incidence of osteonecrosis in HIV-infected patients. As these authors report, the increased survivorship of these patients has led to an increased number of joint arthroplasty procedures and a considerable burden on available healthcare resources, especially in developing countries. However, a direct link between antiretroviral therapy (ART) and osteonecrosis in HIV-infected patients has not been established, and for this reason, we did not include this in the etiology and pathogenesis section. Several case-control studies evaluating risk factors for the development of osteonecrosis in HIVinfected patients have not shown an association with ART.2,3,6-9 Instead, they documented the significantly
February 2015, Vol 23, No 2
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
69
Correspondence
increased presence of already established risk factors, such as corticosteroid use,2,3,7,9 coagulopathy,3 hyperlipidemia,3,4 and alcohol consumption,9 in HIV-infected patients who developed osteonecrosis compared with HIV-infected patients who did not develop the disease. Our suspicion is that there is some type of association, but further study of this issue is needed to define it. Thank you again for highlighting the important problem of osteonecrosis in HIV-infected patients. A high index of suspicion for osteonecrosis in these patients may lead to diagnosis at an earlier stage and treatment with a femoral head-sparing procedure, thereby potentially decreasing the burden of the disease.
70
Charalampos G. Zalavras, MD Jay R. Lieberman, MD Los Angeles, CA
5. Mokete L, Mohideen M, Pietrzak JR, van der Jagt DR: Projections for elective total hip replacement for osteonecrosis of the hip in HIV: is South Africa adequately prepared? Bloemfontein, South Africa, S Afr Orthop Congr, 2014, p 113. 6. Scribner AN, Troia-Cancio PV, Cox BA, et al: Osteonecrosis in HIV: A case-control study. J Acquir Immune Defic Syndr 2000;25(1):19-25.
References 1. Zalavras CG, Lieberman JR: Osteonecrosis of the femoral head: Evaluation and treatment. J Am Acad Orthop Surg 2014;22(7):455-464. 2. Keruly JC, Chaisson RE, Moore RD: Increasing incidence of avascular necrosis of the hip in HIV-infected patients. J Acquir Immune Defic Syndr 2001;28(1):101-102. 3. Miller KD, Masur H, Jones EC, et al: High prevalence of osteonecrosis of the femoral head in HIV-infected adults. Ann Intern Med 2002;137(1):17-25. 4. Matos MA, Alencar RW, Matos SS: Avascular necrosis of the femoral head in HIV infected patients. Braz J Infect Dis 2007;11(1):31-34.
7. Glesby MJ, Hoover DR, Vaamonde CM: Osteonecrosis in patients infected with human immunodeficiency virus: A case-control study. J Infect Dis 2001;184(4):519-523. 8. Hasse B, Ledergerber B, Egger M, et al; Swiss HIV Cohort Study: Antiretroviral treatment and osteonecrosis in patients of the Swiss HIV Cohort Study: A nested case-control study. AIDS Res Hum Retroviruses 2004;20(9):909-915. 9. Lawson-Ayayi S, Bonnet F, Bernardin E, et al; Groupe d’Epidémiologie Clinique du SIDA en Aquitaine: Avascular necrosis in HIV-infected patients: A case-control study from the Aquitaine Cohort, 1997-2002, France. Clin Infect Dis 2005;40(8):1188-1193.
Journal of the American Academy of Orthopaedic Surgeons
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
