Patients with HIV had higher incidence of medical complications, stroke after TSA

More studies are needed to better predict how high-risk patients will perform after total shoulder arthroplasty.

Patients who are HIV-positive and undergo total shoulder arthroplasty experience a higher incidence of early medical complications, specifically cerebrovascular accidents, and long-term surgical complications after index surgery, according to study results.

“Patients with these comorbidities, such as HIV, who previously were not able to get these procedures, are now able to receive them because of better medical co-management with improved surgical techniques. These patients are going to get these procedures more frequently as time progresses,” Abiram Bala, MD, orthopedic surgery resident at Stanford University, told Orthopedics Today. “Even though we have specific medications to help manage medical comorbidities, I think there are certain complications that surgeons need to be aware of in the perioperative period because they may present themselves in surprising ways.”

Higher prevalence of comorbidities

Abiram Bala, MD
Abiram Bala

Searching the Medicare Standard Analytic Files database from 2005 to 2012, Bala and colleagues at Duke University Medical Center, where the study was performed, identified procedure, comorbidities and postoperative complications in 2,528 patients who were diagnosed with HIV infection or AIDS and 145,761 patients who were not diagnosed with HIV and underwent total shoulder arthroplasty (TSA) or reverse TSA. Overall, 1,353 patients with HIV and 90,202 control patients were followed up at a minimum of 2-years.

Results showed patients with HIV were slightly older and had a higher prevalence of comorbidities. Researchers noted higher rates of 90-day cerebrovascular accident in patients who were HIV-positive, as well as higher overall rates of broken prosthetic joints, periprosthetic infection and TSA revision or repair.

Because patients who were HIV-positive were sicker at baseline, Bala noted the high infection and reoperation rates were not surprising. However, the high incidence of cerebrovascular accident was surprising, as it is not frequently seen in the orthopedic literature, he said.

“There [are] now more studies coming out describing postoperative outcomes in HIV-positive patients, and this was the first time [HIV-positive] patients [who underwent TSA] were ever evaluated in larger groups of patients,” Bala said. “To understand the high stroke rate, we had to dig in the medicine literature rather than the orthopedic literature to help explain and rationalize: ‘Does this finding actually make any sense?’ What we found was if you look in the medicine literature, there are some studies that show HIV itself as an independent risk factor for stroke and [the intake] of certain medications — such as the highly active antiretroviral medications — also being possible risk factors for stroke.”

Vigilant postoperative care

However, patients who were HIV-positive and underwent hip and knee replacements did not have the same high incidence rates as patients who had a shoulder replacement, Bala said, and he noted the problem may be due to patients being placed in the beach chair position for TSA.

“There are some data in the anesthesia literature that show there could be decreased blood flow to the brain [with] that positioning and, if you look at the comorbidities in addition to just HIV for those patients, a lot of them also have neurologic disorders, and many have [at] baseline higher hypercoagulable states,” Bala said. “We think it is a combination of these factors that leads to the higher incidence of stroke in these patients.”

Surgeons should not change their anticoagulation regimens for patients who are HIV-positive, Bala said, but surgeons and the surgical team should stay vigilant in their postoperative care of these patients until more research is conducted.

“As the fidelity of database studies improves, we should be able to better predict which high-risk patients perform worse and know how to target these specific complications. Until that time, these studies can give us a reasonable look at how these patients do after surgery,” Bala said. – by Casey Tingle

Disclosure: Bala reports no relevant financial disclosures.

Patients who are HIV-positive and undergo total shoulder arthroplasty experience a higher incidence of early medical complications, specifically cerebrovascular accidents, and long-term surgical complications after index surgery, according to study results.

“Patients with these comorbidities, such as HIV, who previously were not able to get these procedures, are now able to receive them because of better medical co-management with improved surgical techniques. These patients are going to get these procedures more frequently as time progresses,” Abiram Bala, MD, orthopedic surgery resident at Stanford University, told Orthopedics Today. “Even though we have specific medications to help manage medical comorbidities, I think there are certain complications that surgeons need to be aware of in the perioperative period because they may present themselves in surprising ways.”

Higher prevalence of comorbidities

Abiram Bala, MD
Abiram Bala

Searching the Medicare Standard Analytic Files database from 2005 to 2012, Bala and colleagues at Duke University Medical Center, where the study was performed, identified procedure, comorbidities and postoperative complications in 2,528 patients who were diagnosed with HIV infection or AIDS and 145,761 patients who were not diagnosed with HIV and underwent total shoulder arthroplasty (TSA) or reverse TSA. Overall, 1,353 patients with HIV and 90,202 control patients were followed up at a minimum of 2-years.

Results showed patients with HIV were slightly older and had a higher prevalence of comorbidities. Researchers noted higher rates of 90-day cerebrovascular accident in patients who were HIV-positive, as well as higher overall rates of broken prosthetic joints, periprosthetic infection and TSA revision or repair.

Because patients who were HIV-positive were sicker at baseline, Bala noted the high infection and reoperation rates were not surprising. However, the high incidence of cerebrovascular accident was surprising, as it is not frequently seen in the orthopedic literature, he said.

“There [are] now more studies coming out describing postoperative outcomes in HIV-positive patients, and this was the first time [HIV-positive] patients [who underwent TSA] were ever evaluated in larger groups of patients,” Bala said. “To understand the high stroke rate, we had to dig in the medicine literature rather than the orthopedic literature to help explain and rationalize: ‘Does this finding actually make any sense?’ What we found was if you look in the medicine literature, there are some studies that show HIV itself as an independent risk factor for stroke and [the intake] of certain medications — such as the highly active antiretroviral medications — also being possible risk factors for stroke.”

PAGE BREAK

Vigilant postoperative care

However, patients who were HIV-positive and underwent hip and knee replacements did not have the same high incidence rates as patients who had a shoulder replacement, Bala said, and he noted the problem may be due to patients being placed in the beach chair position for TSA.

“There are some data in the anesthesia literature that show there could be decreased blood flow to the brain [with] that positioning and, if you look at the comorbidities in addition to just HIV for those patients, a lot of them also have neurologic disorders, and many have [at] baseline higher hypercoagulable states,” Bala said. “We think it is a combination of these factors that leads to the higher incidence of stroke in these patients.”

Surgeons should not change their anticoagulation regimens for patients who are HIV-positive, Bala said, but surgeons and the surgical team should stay vigilant in their postoperative care of these patients until more research is conducted.

“As the fidelity of database studies improves, we should be able to better predict which high-risk patients perform worse and know how to target these specific complications. Until that time, these studies can give us a reasonable look at how these patients do after surgery,” Bala said. – by Casey Tingle

Disclosure: Bala reports no relevant financial disclosures.