Clinical observations of hiv-infected patients with the femoral head necrosis

Introduction: HIV infection is often accompanied by the development of the femoral head necrosis, but the pathogenesis of this process is still not fully understood. There are few studies in the literature indicating a direct effect of human immunodeficiency virus on osteocytes and osteoblasts. In previously published clinical observations, we presented data on the detection of human immunodeficiency virus RNA directly in foci of osteonecrosis of the femoral head, including those with undetectable viral load in the blood [12].

Purpose of the study: to present the first results of clinical observations in HIV-infected patients with femoral head necrosis, in whom HIV RNA was detected in the focus of bone necrosis.

Methods: patients with HIV infection and femoral head necrosis with undetectable viral load in blood plasma, in whom the viral load in the foci of bone destruction was determined by PCR, were included in the study (n=16). Based on the study of the biopsy material, patients were divided into two groups based on the presence of bacterial agent (coxitis) (n=7, group 1) and its absence (aseptic necrosis) (n=9, group 2).

Results: despite the absence of a significant difference in the groups in terms of the level of CD4 T-lymphocytes, the number of patients with severe immunodeficiency (CD4 T-lymphocytes less than 350 cells/μl) in the group 1 was 42.9% (3/7), in the group 2 was 22.2% (2/9), which suggests, with increasing sample sizes, a greater severity of immunodeficiency in patients with coxitis. Viral load in foci of necrosis in patients of both groups was significantly higher than the undetectable level. In the group 1 treatment was carried out with a with a cement spacer saturated with antimicrobial agents, depending on the individual sensitivity of the pathogen. In the group 2 one-stage arthroplasty was performed. During the follow-up period from 4 to 16 months in the group 1 the average Harris scale score after the first stage of surgery was 61.2±2.4 (23.4±5.1 on admission), and in both patients with tuberculous coxitis progression of the local specific process was noted. In the group 2 after treatment the average Harris score was 87,2±4,5 against 26,7±7,6 on admission, no postoperative complications were noted during the observed period.

1. Biviji A.A., Paiement G.D., Steinbach L.S. Musculoskeletal manifestations of human immunodeficiency virus infection. Journal of the American Academy of Orthopaedic Surgeons. 2002;10(5):312-320. doi: 10.5435/00124635-200209000-00003

2. Bukhanova D.V., Belov B.S. Joint damage in HIV positive patients. Meditsinskiy Sovet. 2018; (9):8287 (In Russian) doi: 10.21518/2079-701X-2018-9-82-87

3. Zhao C. S., Li X., Zhang Q., Sun S., Zhao R. G., Cai J. Early outcomes of primary total hip arthroplasty for osteonecrosis of the femoral head in patients with human immunodeficiency virus in China. Chinese Medical Journal. 2015;128(15):2059-2064. doi: 10.4103/0366-6999.161364

4. Issa K, Naziri Q, Rasquinha V, Maheshwari A.V., Delanois R.E., Mont M.A. Outcomes of cementless primary THA for osteonecrosis in HIV-infected patients. The Journal of bone and joint surgery. American volume. 2013;95(20),1845-1850. doi: 10.2106/JBJS.L.01583

5. Lee S.O., Lee J.E., Lee S., Lee S.H., Kang J.S., Lee I.S. et al. Osteonecrosis of the femoral head in Korean patients with human immunodeficiency virus infection. Infection & Chemotherapy. 2020;52(4):592. doi: 10.3947/ic.2020.52.4.592

6. Zhao R., Ma R., Zhao C., Zhang Q. Risk Factors for Osteonecrosis of the Femoral Head in Human Immunodeficiency Virus-Positive Patients: A Retrospective Case–Control Study. AIDS Research and Human Retroviruses. 2022;38(11):869-874. doi: 10.1089/aid.2021.0224

7. O’Neill, S.C., Queally, J.M., Hickey A., Mulhall K.J. Outcome of total hip and knee arthroplasty in HIV-infected patients: a systematic review. Orthopedic reviews. 2019;11(1):8020. doi: 10.4081/or.2019.8020

8. Youngman T.R., Riepen D.W., Rinehart D.B., Thota D.R., Sun J.J., Telford C.L., Huo M.H. Complications of primary total hip arthroplasty in human immunodeficiency virus-positive patients with femoral head osteonecrosis. Hip International, 2023;33(1):62-66. doi: 10.1177/11207000211005750

9. Lutz A.B., Patel D.V., Bibbo C., Hong I.S., Hameed D., Dubin J., Mont M.A. Total Hip Arthroplasty in Human Immunodeficiency Virus Positive Patients: A Systematic Review of Outcomes. The Journal of Arthroplasty. 2024. doi: 10.1016/j.arth.2024.02.043

10. Falakassa J., Diaz A., Schneiderbauer M. Outcomes of total joint arthroplasty in HIV patients. The Iowa orthopaedic journal. 2014;34:102.

11. Zubikov V.S., Peretsmanas E.O., Gerasimov I.А. The experience of surgical treatment of tuberculosis and non-specific arthritis with two-stage arthroplasty using articulating cement spacers saturated with antibiotics. Tuberculosis and Lung Diseases. 2019;97(11):25-32. (In Russian) doi: 10.21292/2075-1230-2019-97-11-25-32

12. Peretsmanas E.O., Tyulkova T.E., Zubikov V.S., Gerasimov I.A., Kaminsky G.D. Human Immunodeficiency Virus in the Focus of Bone Tissue Destruction in Patients With Aseptic Osteonecrosis of the Femoral Head: Two Case Reports. Traumatology and Orthopedics of Russia. 2023;29(3):94-101. (In Russian). doi: 10.17816/2311-2905-7989.

13. Raynaud-Messina B., Bracq L., Dupont M., Souriant S., Usmani S. M., Proag A. Bone degradation machinery of osteoclasts: An HIV-1 target that contributes to bone loss. Proceedings of the National Academy of Sciences. 2018;115(11): E2556-E2565. doi: 10.1073/pnas.1713370115

14. Sviercz F.A., Jarmoluk P., Cevallos C.G., López C.A., Freiberger R.N., Guano A. et al. Massively HIV-1-infected macrophages exhibit a severely hampered ability to differentiate into osteoclasts. Frontiers in Immunology. 2023;14:1206099. doi: 0.3389/fimmu.2023.1206099

15. Cotter A.G., Mallon P.W. The effects of untreated and treated HIV infection on bone disease. Current opinion in HIV and AIDS. 2014;9(1):17-26. doi: 10.1097/COH.0000000000000028

16. Delpino, M. V., & Quarleri, J. Influence of HIV infection and antiretroviral therapy on bone homeostasis. Frontiers in endocrinology. 2020;11:549865 doi:10.3389/fendo.2020.00502

17. Peretsmanas E.O., Orlova-Morozova E.A., Esin I.V., Kaminsky G.D., Tyulkova T.E., Panova A.E., Lovacheva O. V. O.V. Human Immunodeficiency Virus is One of the Factors Promoting Bone Tissue Inflammation in Tuberculous Spondylitis Associated with HIV Infection. Hypothesis or Reality? Tuberculosis and Lung Diseases. 2023;101(2):47-53. (In Russ.) DOI:10.58838/2075-12302023-101-2-47-53.