HIV Positive Patients at Higher Risk of VTE After TJA
Key findings
- This multicenter, retrospective cohort study compared the risk of venous thromboembolism (VTE) in 110 HIV-positive and 240 HIV-negative patients who underwent total hip or knee arthroplasty
- Postoperative VTE (symptomatic deep vein thrombosis or pulmonary embolism within 90 days) occurred in four HIV+ patients (3.6%) vs. one control (0.4%; P=0.02)
- By procedure, postoperative VTE occurred in 2.5% of HIV+ patients who underwent total hip arthroplasty and 8% who underwent total knee arthroplasty
- VTE occurred a median of 40 days after surgery (interquartile range, 1–52) in the HIV+ group vs. three days in the single control subject
- HIV infection was an independent predictor of perioperative VTE (OR, 10.9; 95% CI, 1.0–114.0; P=0.046)
Now that Human Immunodeficiency Virus (HIV) is a manageable chronic disease, a growing number of HIV+ patients are living long enough to require total joint replacement (TJR). Because HIV infection is a hypercoagulable state and venous thromboembolism (VTE) is a serious potential complication of TJR, the relationship between the disease and the surgical complication begs exploration.
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Jeffrey J. Olson, MD, of the Harvard Combined Orthopaedic Residency Program, Hany S. Bedair, MD, surgeon in the Center for Hip and Knee Replacement in Department of Orthopedic Surgery at Massachusetts General Hospital, and colleagues recently used a hospital research–based registry to study VTE in a large cohort of HIV+ patients who underwent TJR. In the Journal of the American Academy of Orthopaedic Surgeons, they report that the odds of VTE were 11 times higher for HIV+ patients than for a matched HIV− control group.
Study Methods
The researchers identified 16,066 adults who underwent primary total hip arthroplasty (THA) and 23,038 who underwent primary total knee arthroplasty (TKA) at three tertiary care centers between January 2000 and December 2018. Of those, 110 patients (85 hips and 25 knees) were HIV+. The team also identified 240 HIV− control patients (180 hips and 60 knees) who were similar in age, sex and surgical procedure.
Incidence of VTE
Postoperative VTE, defined as symptomatic deep vein thrombosis or pulmonary embolism within 90 days, occurred in:
- Overall cohort—Four HIV+ patients (3.6%) vs. one control (0.4%; P=0.02)
- THA group—2.5% vs. 0%
- TKA group—8% vs. 1.7%
VTE occurred a median of 40 days after surgery (interquartile range, 1–52) in the HIV+ group, versus three days in the single control subject.
Prophylactic anticoagulation had been used in 98% of patients postoperatively (low-molecular-weight heparin, 73%; warfarin, 19%; aspirin, 6% and clopidogrel, 1%). Four HIV+ patients were not anticoagulated because of a diagnosis of hemophilia, but none of them developed postoperative VTE.
Multivariable Analysis
After adjustment for sex, smoking, history of VTE and type of joint replaced, HIV infection was an independent predictor of postoperative VTE (OR, 10.9; 95% CI, 1.0–114.0; P=0.046).
Reconsidering the Guidelines
National guidelines currently recommend VTE prophylaxis for 10–35 days after TJR. There is a trend toward the use of low-dose aspirin for this purpose because it is cost-effective and has been found to be safe for many patients. Considering these study findings, best practices may need to differ for postoperative prophylaxis in HIV+ patients.
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