From Harvard Combined Orthopaedic Residency Program (Olson), Department of Orthopaedic Surgery, Brigham and Women's Hospital (Schwab and Lange), Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center (Jackson and Abdeen), and Department of Orthopaedic Surgery, Massachusetts General Hospital (Bedair), Boston, MA.
J Am Acad Orthop Surg. 2021 Jun 1;29(11):479-485. doi: 10.5435/JAAOS-D-20-00737.
Antiretroviral therapy has improved the life expectancy of HIV patients, leading to an increase in total joint replacement for age-related osteoarthritis. HIV patients are inherently hypercoagulable at baseline. The goal of our study was to compare the incidence of venous thromboembolism (VTE) in HIV patients with HIV-negative controls after total joint replacement.
A multicenter, retrospective cohort study of 110 HIV patients (85 hips and 25 knees) and 240 HIV-negative controls (180 hips and 85 knees) between 2000 and 2018. Prophylactic anticoagulation was used in 98% of patients postoperatively-low-molecular weight heparin (73%), warfarin (19%), aspirin (6%), and clopidogrel (1%).
The VTE rate was 3.6% in the HIV-positive group (2.5% total hip arthroplasty [THA] and 8.0% total knee arthroplasty [TKA]) and 0.4% in the control group (0% THA and 1.7% TKA). VTEs occurred at the median (interquartile range) time of 40 days (1 to 52) post-op in the HIV group and 3 days post-op in the one control. Multivariable logistic regression adjusting for sex, smoking, history of VTE, and joint replaced identified HIV as an independent predictor of VTE (odds ratio 10.9, 95% confidence interval 1.1 to 114.0, P = 0.046). All patients with VTE were treated with warfarin (5 to 9 months); two cases were complicated by hemarthrosis and excessive bleeding at the insulin injection site.
We observed increased rates of symptomatic VTE in HIV patients after THA (2.5%) and TKA (8%) compared with HIV-negative control patients (0% and 1.7%, respectively). HIV positivity was identified as an independent predictor of perioperative VTE. Our data suggests that HIV patients may be at higher risk for post-op VTE than HIV-negative patients. Surgeons may want to consider the use of more potent anticoagulation (ie, warfarin or novel anticoagulants) for a longer duration in HIV-positive patients. However, further studies are necessary to form evidence-based guidelines regarding this practice.
Level III, prognostic.
抗逆转录病毒疗法提高了 HIV 患者的预期寿命，导致因年龄相关性骨关节炎而进行全关节置换的人数增加。HIV 患者在基线时就存在固有高凝状态。我们的研究目的是比较 HIV 患者与 HIV 阴性对照者在全关节置换术后静脉血栓栓塞（VTE）的发生率。
这是一项 2000 年至 2018 年间进行的多中心、回顾性队列研究，共纳入 110 例 HIV 患者（85 髋和 25 膝）和 240 例 HIV 阴性对照者（180 髋和 85 膝）。98%的患者术后接受预防性抗凝治疗-低分子肝素（73%）、华法林（19%）、阿司匹林（6%）和氯吡格雷（1%）。
HIV 阳性组的 VTE 发生率为 3.6%（全髋关节置换术[THA]2.5%，全膝关节置换术[TKA]8.0%），对照组为 0.4%（THA 0%，TKA 1.7%）。HIV 阳性组 VTE 发生在术后中位数（四分位距）40 天（1-52 天），对照组为术后 3 天。多变量逻辑回归调整性别、吸烟、VTE 史和关节置换类型后，HIV 是 VTE 的独立预测因子（比值比 10.9，95%置信区间 1.1 至 114.0，P = 0.046）。所有 VTE 患者均接受华法林治疗（5-9 个月）；2 例患者因关节内血肿和胰岛素注射部位过度出血而出现并发症。
与 HIV 阴性对照者（分别为 0%和 1.7%）相比，我们观察到 HIV 患者在接受 THA（2.5%）和 TKA（8%）后出现症状性 VTE 的发生率增加。HIV 阳性被确定为围手术期 VTE 的独立预测因子。我们的数据表明，与 HIV 阴性患者相比，HIV 患者术后发生 VTE 的风险可能更高。外科医生可能需要考虑在 HIV 阳性患者中使用更有效的抗凝药物（如华法林或新型抗凝药物）更长时间。但是，需要进一步的研究来制定关于这种治疗方法的循证指南。
III 级，预后。
