Therefore, it is important to develop methods that can ensure the safety of both the patients and medical personnel who participate in surgery on HIV-infected patients.
Recently, the authors performed 8 procedures on 5 HIV-infected patients. This paper reports our experience. Methods: This study examined the medical records and radiological studies of 5 HIV-infected patients who had undergone surgery around the hip joint from January, to September, During the procedures, their mean age was Four of them were under an anti-retroviral therapy program. The reasons for the operations were nonunion of the femoral shaft after trauma in two patients and osteonecrosis of both femoral heads in three.
In addition, the safety of medical personnel can be assured when the operation is performed in line with the guidelines of HIV infection control.
According to the statistics, the number of human immunodeficiency virus HIV -infected people in Korea reached 5, in January with 4, of them still alive, and the number of cases is growing steadily.
Many studies have reported that patients infected with HIV have a high incidence of osteonecrosis of the femoral head. Therefore, medical personnel should be equipped with a solid understanding of the surgical procedures performed on HIV-infected patients. Moreover, a study on the impact of HIV infections on the surgical outcomes will be needed to promote the safety of both medical personnel and patients during orthopedic surgery.
The authors recently performed eight operations on five HIV-infected patients. This paper is based on our experience and focuses on the preoperative preparations, caution taken during surgery, and the risk of early postoperative complications.
Of the patients who had undergone surgery around the hip joint at our institution between January and September , five patients with a HIV infection confirmed by enzyme-linked immunosorbent assay ELISA and Western blotting were included. Their medical records internal medicine and orthopedics , laboratory test results, and radiographs were analyzed.
All five patients were male with an average age of Four of the patients had been on anti-retroviral treatment for an average of 23 months range, 2 to 34 months prior to surgery, while it was started after surgery in the remaining one patient, who had been diagnosed with HIV immediately before surgery. The infection route was heterosexual contact in two of the five patients.
The probable infection route was either homosexual or heterosexual contact in another patient who was bisexual. Surgery was required for nonunion after a femoral fracture that occurred in a traffic accident and for bilateral osteonecrosis of the femoral head in two and three patients, respectively. Regarding the surgical procedures, autologous bone grafting was performed in one case, screw fixation with autologous bone grafting in one, total hip replacement arthroplasty in five, and multiple drilling in one.
The mean duration from confirmation of the HIV infection to surgery in the five patients ranged from five months to nine years, respectively Table 1.
Only essential surgical instruments were available in the operating room and the operating table was covered with vinyl. The walls and instruments in the operating room were covered with disposable linen and the drainage bucket was also disposable. All the surgeons involved in the surgery wore waterproof gowns, caps, masks, head gear, two pairs of sterilized gloves, and protective boots. To prevent occurrence of injuries to the medical personnel during surgery, the needles and knives were handed over indirectly through a space set up between the surgeons and nurses.
Postoperatively, all the surgical instruments and tissues were tagged with an HIV infection mark to ensure that they were easily recognizable by other personnel at our institution Fig. Preparation of the operating room and operator. The mean postoperative follow-up period was During the regular follow-up examination performed on an outpatient basis, an ordinary blood test, T cell subset test and radiological test were carried out.
The Harris Hip Scores was also measured in patients who had undergone hip replacement arthroplasty. Of the two patients two cases with nonunion after a femoral fracture, one was treated with an autologous bone graft and the other underwent screw fixation with autologous bone grafting.
Both achieved bone union and were followed up for eight months and 37 months, respectively. The patient who had been followed for eight postoperative months died from esophageal variceal bleeding at the 14th postoperative month Fig. Preoperative and postoperative X-ray of one nonunion patient.
The postoperative X-ray shows that a callus had formed and union was achieved. Of the three patients six cases with osteonecrosis of the femoral head, five cases were treated with hip replacement arthroplasty and one with multiple drilling. Two of them underwent a two of bilateral hip replacement procedures under spinal anesthesia with an interval of four months and two months respectively.
The surgical time was , , , and minutes, respectively. Significant improvements in the Harris Hip Score and functional state were noted during 4, 6, and 28 month follow-up examination.
There were no acute postoperative complications, such as infection, early loosening of implants, and dislocation. The one patient without preoperative anti-retroviral treatment was placed on anti-retroviral treatment postoperatively and the remaining four patients were on the anti-retroviral treatment that they had received preoperatively Fig.
At the final follow-up, excluding the patient who died from esophageal variceal bleeding, the remaining four patients showed no complications associated with the orthopedic surgery. Preoperative and postoperative X-ray of one osteonecrosis patient. The postoperative X-ray shows no evidence of complications, such as loosening or infection.
The report of the Korea Centers for Disease Control and Prevention, 'Knowledge, attitudes, beliefs, and practices on HIV', shows that people's knowledge of AIDS is improving but is still at a low level compared to advanced countries. Discriminative attitudes toward HIV-infected patients were also reflected in the survey results of that report: Similarly, HIV-infected patients are not accepted in most medical institutions and are even referred to university hospitals by tertiary hospitals.
These attitudes can be attributed to ignorance of the infection control guidelines and a lack of treatment experience. Many authors reported that the incidence of osteonecrosis of the femoral head is high among HIV-infected patients.
For example, Miller et al. In that study, osteonecrosis was diagnosed in 4. In addition, they found that the incidence was times higher in infected individuals than in ordinary people. Ries et al. HIV-infected patients are vulnerable to infection after hip replacement arthroplasty or surgery after trauma. According to Lehman et al. The percentage was remarkably high compared to that in non-infected people. Parvizi et al. Hoekman et al. Paiement et al. However, some recent reports showed that there was no increase in the postoperative infection rates among HIV-infected patients postoperatively.
In the prospective study of Harrison et al. Mahoney et al. They postulated that the improvement in the management of the HIV-infected patients resulted in such outcomes. In the present study, no case of postoperative infection was encountered.
Although this study was based on a small number of patients, it is believed that a proper evaluation of the immune system before surgery and thorough enforcement of the guidelines during surgery contributed to such satisfactory outcomes. Medical practitioners are exposed to a risk of infection during surgery from the blood and body fluids of HIV-infected patients.
Therefore, it is important to be fully aware of the safety practices used during treatment. One epidemiological study described the risk of HIV infections in medical personnel after transcutaneous exposure as 0. Currently, 4, people, approximately 0. If a surgeon is exposed to infected blood about 10 times a year during surgery for 40 years, then the surgeon has a 0.
However, considering that orthopedic surgery involves sharp and high-speed metal equipment to deal with hard and sharp tissues, such as fractured bones, these surgeons are more likely to be injured during surgery.
Therefore, it is our understanding that orthopedic surgeons should pay special attention to the fact that they are exposed to a higher risk of infection than indicated by the above-cited reports. In particular, based on reports that osteonecrosis can be found in 4. The purpose of this study was to provide an extended follow-up on a previously published study on a cohort of HIV-positive THA recipients in an effort to confirm the safety and longevity of THA in this population.
At this follow-up, 5 patients from the original cohort required contralateral THA. Postoperative complications were recorded up to the patient's last follow-up date.
A survivorship analysis was performed using the Kaplan-Meier method with revision THA as the end point.
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