Avascular necrosis: a growing concern for the HIV population.

A 33-year-old woman with history of HIV presented with 4 months of gradually progressing right hip pain and was found to have avascular necrosis (AVN) of both femoral heads. She had no other risk factors for AVN including sickle cell disease, systemic lupus erythematosus, prolonged steroid used or trauma. She initially failed conservative management and ultimately had bilateral hip core decompressions. After decompression therapy, the left femoral head collapsed and patient underwent a left total hip arthroplasty. Her postsurgical course was complicated by the left sciatic nerve neuropathy for which she is currently being managed with duloxetine. She has yet to follow-up with her orthopaedic surgeon for further evaluation.

Total hip arthroplasty in HIV-infected patients: a retrospective, controlled study.

BACKGROUND: Although HIV-infected patients are at greater risk of presenting with ischaemic necrosis of the femoral head, there have been concerns about whether total hip arthroplasty (THA) may have worse outcomes than expected. METHODS: From the Orthopedic and Trauma Surgery database we identified all patients who had undergone THA because of ischaemic necrosis of the femoral head from January 2001 until March 2010. Patient's diagnosis of HIV infection was confirmed at the time of arthroplasty by cross-matching with the HIV unit database. For every THA in HIV-infected patients, two THAs in patients not known to be HIV-infected, with the same diagnosis of ischaemic necrosis of the femoral head and having undergone surgery over the same period, were randomly selected. THAs were compared in HIV- and non-HIV-infected patients for surgical procedure, in-patient stay and long-term prognosis. RESULTS: There were 18 THAs in 13 HIV-infected patients and 36 THAs in 27 non-HIV-infected patients. No significant differences were observed in the mean time spent in surgery (106 vs. 109 minutes, respectively; P = 0.66), the need for red cell transfusion (1 vs. 4, respectively; P = 0.48) or the mean duration of hospitalization (7.8 vs. 9.4 days, respectively; P = 0.48). The two groups showed similar postoperative functional results, which were maintained until the end of the follow-up period (median 3.3 years in the HIV-positive group and 5.8 years in the HIV-negative group). CONCLUSION: Our study suggests that the outcome of THA in HIV-positive patients is not worse than that of HIV-negative patients, although future research on larger numbers of patients is required to confirm this.

Pulsed radiofrequency treatment of articular branches of the obturator and femoral nerves for management of hip joint pain.

Groin and thigh pain are frequently the major symptoms of hip joint pathology. The hip joint is innervated by articular branches of the obturator, femoral, superior gluteal, and sciatic nerves. The nerve responsible for hip joint pain can be determined by a diagnostic nerve block. Radiofrequency ablation of the identified articular branches of the hip was demonstrated to provide relief of hip pain. However, continuous radiofrequency denervation by thermal coagulation carries the potential risk of neuritis. We report on two patients with groin and thigh pain related to hip joint pathology treated with a novel technique for hip pain relief, pulsed radiofrequency treatment (PRF) of articular branches of the obturator and femoral nerves. At the time this case was written, both patients demonstrated at least 50% pain relief 3 to 4 months after the intervention along with improved function (increased ambulation and ability to participate in physical therapy). Our clinical observation suggests that PRF of articular branches of the hip joint may be an alternative treatment for patients with intractable hip pain.

Aseptic necrosis in HIV seropositive patients: a possible etiologic role for megestrol acetate.

The association between pharmacologic doses of corticosteroids and the development of aseptic bone necrosis has been well documented. Recent reports have described the corticosteroid activity of megestrol acetate. A retrospective review of adverse events reported to the U.S. Food and Drug Administration identified three human immunodeficiency virus (HIV) seropositive patients who developed avascular necrosis of the femoral head during treatment with megestrol acetate. All were males, ages 34, 36, and 55 years, and were on therapy for 6, 1.5, and 18 months, respectively, when symptoms of aseptic necrosis occurred in the absence of antecedent trauma. Megestrol acetate doses were 640, 320, and 600-1200 mg/d, respectively. Two patients had no history of corticosteroid use whereas the third had taken an undisclosed dose and duration of corticosteroids concurrent with pentamidine administration. Notably, despite the predominant use of megestrol in women for hormone sensitive malignancies, none of the reports of aseptic necrosis occurred in this population. Megestrol acetate may be associated with the development of avascular necrosis via its glucocorticoid-like effects. Cachectic acquired immunodeficiency syndrome (AIDS) patients may have additional risk factors that predispose them to aseptic necrosis when receiving megestrol acetate.