Introduction

Visiting clinicians need to be aware of the special considerations for orthopedic surgical care in patients with HIV/AIDS and the appropriate measures to prevent and treat occupational exposures. The human immunodeficiency virus (HIV) is a retrovirus that hides within the RNA of host cells. It targets T-helper (CD4) cells, depleting them in number and effectiveness, reducing host defenses and surveillance, and increasing the risk of infections and certain tumors.

There are an estimated 36.7 million HIV-positive individuals worldwide, approximately two thirds, 25.5 million, live in sub-Saharan Africa [1] with a higher prevalence in southern Africa. Trauma patients have a higher seroprevalence rate compared with national averages [2]. The South and Southeast Asian region have approximately 5.1 million persons infected. New diagnoses have decreased globally since 2001 to 1.8 million in 2016, and the annual number of deaths has fallen from 1.9 million in 2005 to 1 million in 2016.

Combination drug therapy, highly active antiretroviral therapy (HAART), has become increasingly available in resource-poor settings since 2003. HAART is effective in prolonging life, restoring activity levels, preventing maternal-fetal transmission, reducing infectivity, and generally improving the quality of life. Previously indications for HAART included (1) progression to AIDS (Pneumocystis carinii pneumonia), (2) CD4 count of ≤250 cells/mm, and (3) prevention of maternal-fetal transmission, but many countries now treat all infected persons. These drugs are associated with significant side effects , some of which affect the musculoskeletal system.

Relevant Issues for Orthopedics and Traumatology

Several common associations between musculoskeletal diseases and HIV have been identified. Arthropathies are seen in adults and children—most commonly Reiter’s syndrome and psoriatic arthropathy—and the clinician must differentiate inflammatory arthropathy from acute septic arthritis. While septic arthritis in association with HIV is unusual until immunity has been substantially reduced, inflammatory joint problems can occur at any stage.

Avascular necrosis (AVN), especially of the femoral head, occurs with HIV, though the pathogenesis remains unclear. AVN has been identified in patients on protease inhibitors, but some patients are symptomatic before starting HAART [3]. Recently, osteoporosis associated with treatment has received considerable attention in the Western literature, particularly after prolonged use of HAART. In sub-Saharan Africa, this entity is not well described, perhaps because the use of HAART has been limited until recently.

Infection with HIV/AIDS must always be suspected when adults are diagnosed with septic arthritis. The association in children is not as strong [4]. Other conditions seen with frequency include other musculoskeletal infections (tuberculosis [5] osteomyelitis, and pyomyositis) and malignancies (Kaposi’s sarcoma, non-Hodgkin’s lymphoma). The association between HIV and TB is quite common and of particular interest to the orthopedic surgeon, as tuberculous musculoskeletal infections are much more frequent in HIV-infected patients. Fungal bone and joint infections should be considered in atypical cases. Histology may be the easiest way to make diagnoses of fungal and tuberculous infections.

Those providing surgical care to patients with HIV/AIDS should be aware of how outcomes can be influenced, and misconceptions are common. The optimal method of fracture reduction and stabilization depends on the time of presentation, severity of soft tissue and other injuries, and local resources. There is no increased risk of wound infection following internal fixation of closed fractures in patients with HIV/AIDS if surgical conditions are sterile [2, 6]. There is no need for prolonged antibiotic coverage; however, the risk of wound infection following an open fracture is greater in HIV patients [7, 8], and in the author’s experience, this risk can be reduced by aggressive early debridement, skeletal stabilization, early soft tissue reconstruction, and negative-pressure wound therapy. Pin-track infections following external fixation are more common but are usually manageable with simple antibiotics [9].

While some reports suggest fracture union rates are lower in patients with HIV/AIDS due to an impaired inflammatory response [7, 8], our experience has not supported this [10]. The impact of HAART on bone union is currently under investigation, and delayed fracture union may be an association although its clinical significance has not yet been proved. Delayed sepsis of an existing implant has been described, but it is unclear whether this represents reactivation of latent infection or a recent hematogenous seeding. In our experience this is an uncommon complication, and it is unnecessary to routinely remove implants. Patients with HIV/AIDS may be candidates for joint replacement, particularly total hip arthroplasty after osteonecrosis or trauma. The limited information shows that patients have satisfactory results at early and medium-term follow-up with both uncemented and cemented implants; however, late sepsis remains a concern [11, 12].

Occupational Hazards

The risk of seroconversion after an occupational exposure depends on the size of inoculation (higher in open injuries, hollow needles), the patient’s viral load (highest at initial seroconversion and in late, untreated disease), and early access to postexposure prophylaxis. Published information indicates that the overall risk after exposure is approximately 0.3%, and this can be reduced up to tenfold by postexposure prophylaxis (PEP) [13]. HAART reduces the patient’s viral load dramatically, reducing the patient infectivity to health providers. The risk from exposure through local contact with mucous membranes is less than from a needle stick or bone spike puncture.

Prevention is better than cure, and clinical staff must make every effort to reduce their exposure to HIV. In the author’s practice, preoperative screening is only used to optimize patients for surgery and occasionally to guide decision-making or inform prognosis. We prefer to view all patients as potentially infected. This awareness should also reduce the exposure risks of hepatitis B and C. In the operating room, all personnel should wear protective eye wear or face shields and double glove. Sharp instruments (scalpels, needles) should be placed in a kidney basin on a safe surface and not passed between staff. Needles are not re-sheathed but kept in the kidney dish until disposal in a sharps bin. Clear spoken communication when moving sharps may reduce accidents. The author generally favors longer wounds to give better visualization and avoids blind finger probing around sharp bony edges. Instruments are used to reduce and hold bone fragments rather than fingers. Care must be taken to avoid excessive force, and tissues should not be devitalized when gaining exposure.

A hospital policy for PEP should be in place, and all staff need to be familiar with the protocol. The injury is immediately washed with soap and water and allowed to bleed, and mucous membranes are flushed copiously with water. The clinician and patient should immediately be tested for HIV and the patient counseled regarding the event. In our experience, PEP is indicated when the patient is HIV positive and the clinician is HIV negative , although protocols vary between institutions and will evolve over time. The regime chosen depends on judged exposure risk, and treatment should be commenced as early as possible after exposure. Ideally, the results of blood tests are available within a few hours, and if not, the decision to begin PEP is based on clinical circumstances. This typically involves a 1-month course of antiretroviral therapy, though the specific regimes often change, depending on local variables. Physicians traveling to endemic regions where PEP is unavailable should consider carrying a starter pack for PEP.