Coinfection with Hepatitis C and HIV Is a Risk Factor for Poor Outcomes After Total Knee Arthroplasty

Infectious Diseases Among People Experiencing Homelessness: A Systematic Review of the Literature in the United States and Canada, 2003-2022

Homelessness increases the risk of acquiring an infectious disease. We conducted a systematic review of the literature to identify quantitative data related to infectious diseases and homelessness. We searched Google Scholar, PubMed, and SCOPUS for quantitative literature published from January 2003 through December 2022 in English from the United States and Canada. We excluded literature on vaccine-preventable diseases and HIV because these diseases were recently reviewed. Of the 250 articles that met inclusion criteria, more than half were on hepatitis C virus or Mycobacterium tuberculosis. Other articles were on COVID-19, respiratory syncytial virus, Staphylococcus aureus, group A Streptococcus, mpox (formerly monkeypox), 5 sexually transmitted infections, and gastrointestinal or vectorborne pathogens. Most studies showed higher prevalence, incidence, or measures of risk for infectious diseases among people experiencing homelessness as compared with people who are housed or the general population. Although having increased published data that quantify the infectious disease risks of homelessness is encouraging, many pathogens that are known to affect people globally who are not housed have not been evaluated in the United States or Canada. Future studies should focus on additional pathogens and factors leading to a disproportionately high incidence and prevalence of infectious diseases among people experiencing homelessness.

A scoping review of surgical care for people experiencing homelessness: prevalence, access, and disparities

BACKGROUND

Numerous studies have highlighted the inequitable access to medical and psychiatric care that people experiencing homelessness (PEH) face, yet the surgical needs of this population are not well understood. We sought to assess evidence describing surgical care for PEH and to perform a thematic analysis of the results.

METHODS

Ovid MEDLINE, Embase, and Web of Science were searched using the terms "surgery" AND "homelessness." Grey literature was also searched. We used a stepwise scoping review methodology, followed by thematic analysis using an inductive approach.

RESULTS

We included 104 articles in our review. Studies were included from 5 continents; 63% originated in the United States. All surgical specialties were represented with varying surgical conditions and procedures for each. Orthopedic surgery (21%) was the most frequently reported specialty. Themes identified included characteristics of PEH receiving surgical care, homeless-to-housed participants, interaction with the health care system, educational initiatives, barriers and challenges, and interventions and future strategies.

CONCLUSION

We identified significant variation and gaps, representing opportunities for further research and interventions. Further addressing the barriers and challenges that PEH face when accessing surgical care can better address the needs of this population.

A meta-analysis of postoperative outcomes of patients with and without chronic hepatitis C undergoing primary total hip or knee arthroplasty

Purpose

This investigation provides a rigorous systematic review of the postoperative outcomes of patients with and without chronic hepatitis C who underwent total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Methods

We queried PubMed, Embase, Cochrane Database of Systematic Reviews, Scopus, Web of Science and the 'gray' literature, including supplemental materials, conference abstracts and proceedings as well as commentary published in various peer-reviewed journals from 1992 to present to evaluate studies that compared the postoperative outcomes of patients with and without chronic hepatitis C who underwent primary THA or TKA. This investigation was registered in the PROSPERO international prospective register of systematic reviews and follows the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. In our literature search, we identified 14 articles that met our inclusion criteria and were included in our fixed-effects meta-analysis. The postoperative outcomes analyzed included periprosthetic joint infection (PJI), aseptic revision, non-homebound discharge and inpatient mortality.

Results

Our statistical analysis demonstrated a statistically significant increase in postoperative complications of patients with chronic hepatitis C who underwent primary THA or TKA including PJI (odds ratio (OR): 1.98, 95% CI: 1.86 - 2.10), aseptic revision (OR: 1.58, 95% CI: 1.50 - 1.67), non-homebound discharge (OR: 1.31, 95% CI: 1.28- 1.34) and inpatient mortality (OR: 9.37, 95% CI: 8.17 - 10.75).

Conclusion

This meta-analysis demonstrated a statistically significant increase in adverse postoperative complications in patients with chronic hepatitis C who underwent primary THA or TKA compared to patients without chronic hepatitis C.

Complications of primary total hip arthroplasty in human immunodeficiency virus-positive patients with femoral head osteonecrosis

BACKGROUND

Femoral head osteonecrosis (FHON) is a well-recognised complication in patients with human immunodeficiency virus (HIV) infection. Total hip arthroplasty (THA) is a reliable solution to FHON and has provided functional improvement and pain relief in these patients. Higher complication rates, in particular infections, have been reported in the series of THAs done in the HIV-positive patients. The purpose of this study was to evaluate the complication rate of THA for FHON in HIV-positive patients managed with the highly active antiretroviral therapy (HAART) protocols.

METHODS

A retrospective review was performed of HIV-positive patients with FHON who underwent THAs over a 10-year period at a single institution.

RESULTS

A total of 56 THAs (44 patients) met the inclusion criteria. The mean age at the time of THAs was 47 (range 34-60) years. Of the 44 patients, 39 (88.6%) were males. The mean follow-up was 6.6 (range 2.0-11.3) years. The overall complication rate was 12.5%, with 2 (3.6%) cases of deep periprosthetic infections.

CONCLUSIONS

HIV-positive patients with FHON undergoing THAs do have a considerable complication rate (12.5%). The deep periprosthetic infection rate (3.6%) in these patients, however, has decreased with contemporary disease modification protocols.

Surgical Care of Patients Experiencing Homelessness: A Scoping Review Using a Phases of Care Conceptual Framework

Homelessness is a growing concern across the world, particularly as individuals experiencing homelessness age and face an increasing burden of chronic health conditions. Although substantial research has focused on the medical and psychiatric care of patients experiencing homelessness, literature about the surgical care of these patients is sparse. Our objective was to review the literature to identify areas of concern unique to patients experiencing homelessness with surgical disease. A scoping review was conducted using a comprehensive database for studies from 1990 to September 1, 2020. Studies that included patients who were unhoused and discussed surgical care were included. The inclusion criteria were designed to identify evidence that directly affected surgical care, systems management, and policy making. Findings were organized within a Phases of Surgical Care framework: preoperative care, intraoperative care, postoperative care, and global use. Our search strategy yielded 553 unique studies, of which 23 met inclusion criteria. Most studies were performed at public and/or safety-net hospitals or via administrative datasets, and surgical specialties that were represented included orthopedic, cardiac, plastic surgery trauma, and vascular surgery. Using the Surgical Phases of Care framework, we identified studies that described the impact of housing status in pre- and postoperative phases as well as global use. There was limited identification of barriers to surgical and anesthetic best practices in the intraoperative phase. More than half of studies (52.2%) lacked a clear definition of homelessness. Thus, there is a marked gap in the surgical literature regarding the impact of housing status on optimal surgical care, with the largest area for improvement in the intraoperative phase of surgical and anesthetic decision making. Consistent use of clear definitions of homelessness is lacking. To promote improved care, a standardized approach to recording housing status is needed, and studies must explore vulnerabilities in surgical care unique to this population.

Hepatitis C virus infection increases the risk of adverse outcomes following joint arthroplasty: A meta-analysis of observational studies

BACKGROUND

Whether hepatitis C virus (HCV)-positive patients are at risk for increased complications and long hospital stay following total joint arthroplasty (TJA) remains unclear. Therefore we performed a meta-analysis aiming to answer the following question: (1) are there differences in postoperative complications including joint infection and mortality between patients with or without hepatitis C following TJAs? (2) Are patients without HCV be associated with less blood loss, shorter hospital stay, lower readmission rate, higher function scores, lower revision and reoperation rates than patients with HCV?

METHODS

A meta-analysis was conducted to pool data and quantitatively assessing the association between HCV infection and risks for adverse postoperative outcomes. A systematic search of all published studies concerning HCV and TJA was performed in five bibliographic databases, including PubMed, EMBASE, China National Knowledge Infrastructure, Web of Science, and the Cochrane Library databases. Random-effects meta-analysis of odds ratios (OR) was accomplished according to the classification of adverse events, subgroup analyses were performed based on surgery type.

RESULTS

Fifteen eligible observational studies were included with a sample size of 9,788,166 patients. Overall pooled data revealed the increased risk of overall complications, including medical and surgical complications, in HCV-positive patients undergoing TJA compared with than in HCV-negative people (OR 1.57; 95%CI: 1.44-1.71 [p<0.00001]). Joint infections were highly common in HCV-positive patients undergoing lower-extremity TJA (OR 2.06; 95%CI: 1.73-2.47 [p<0.00001]). Furthermore, HCV infections were associated with high rates of reoperations and revisions (OR 1.47; 95%CI: 1.40-1.55 [p<0.00001]).

CONCLUSIONS

Patients with hepatitis C have an increased risk of adverse outcomes post-TJA and a high risk of reoperation and revision that is partially attributed to postoperative complications, particularly joint infections.

LEVEL OF EVIDENCE

III; systematic review and meta-analysis.

Hepatitis C Antiviral Treatment Decreases All-Cause Complications After Total Joint Arthroplasty Regardless of the Presence of Fibrosis

BACKGROUND

Patients with hepatitis C virus (HCV) have an increased risk of complications after total joint arthroplasty (TJA). There is a limited but growing body of evidence on the benefit of preoperative antiviral treatment to reduce complications after TJA. What has not been well established is the effect of preoperative antiviral treatment among those with advanced disease as indicated by hepatic fibrosis.

METHODS

In total, 270 patients at 2 urban medical centers were reviewed for patient demographics, comorbidities, HCV treatment, hepatic fibrosis status, surgical information, and postoperative complications. Patients were divided into 2 groups based on their antiviral treatment status prior to TJA: Treated (n = 129) and Untreated (n = 141). Pearson's chi-squared test, Student's t-test, and multivariate logistic regressions were used to analyze complications between groups.

RESULTS

Patients in the Treated group had significantly fewer all-type complications (4.7% vs 14.9%, P = .007), infections (2.3% vs 12.1%, P = .002), and reoperations (0.8% vs 9.9%, P = .001) compared to the Untreated group. After controlling for hepatic fibrosis, we found that Treated patients still had significantly lower odds of experiencing all-type complications (odds ratio [OR] 0.30, 95% confidence interval [CI] 0.10-0.88; P = .028), infection (OR 0.19, 95% CI 0.04-0.87; P = .033), and reoperation (OR 0.11, 95% CI 0.01-0.90; P = .039) following TJA.

CONCLUSION

HCV antiviral treatment reduces postoperative complications after primary TJA, even among those who have progressed to hepatic fibrosis. Surgeons can use this information in shared decision making prior to TJA to counsel patients about the benefits of preoperative antiviral treatment even in the presence of hepatic fibrosis.

Coinfection of HIV and hepatitis C increases complication rates after total joint arthroplasty

INTRODUCTION

As advances in efficacy of human immunodeficiency virus (HIV) and hepatitis-C virus (HCV) anti-viral medications increase, patients are able to maintain higher quality of lives than ever before. While these patients live longer lives, the unique patient population of those co-infected with both HIV and HCV increases. As these older patients seek orthopaedic care, it is important to understand their unique outcome profile. The purpose of this study was to evaluate the complication rate after total joint arthroplasty (TJA) in patients with HIV and HCV coinfection compared with patients with HIV or HCV only.

METHODS

A retrospective review of patients undergoing primary total joint arthroplasty (TJA) at our urban, academic hospital between April 2016 and April 2019 was conducted. Patients were stratified into three groups according to viral status: HIV only, HCV only, or HIV and HCV coinfection. Baseline demographics, intravenous drug (IV) use, surgery type, CD4+ count, follow-up and complications were analysed.

RESULTS

Of the 133 patients included in the study, 28 had HIV, 88 had HCV and 17 were coinfected with both HIV and HCV. Coinfected patients were more likely to have a lower BMI (p < 0.039) and a history of IV drug use (p < 0.018) compared to patients with either HIV or HCV only. Coinfected patients had a higher complication rate (41%) than both HIV only (7%; p < 0.001) and HCV only (12.5%; p < 0.001) patients.

DISCUSSION

Patients coinfected with HIV and HCV undergoing TJA have a higher complication rate than patients with either infection alone. As this unique population of coinfected patients continues to expand, increasingly they will be under the care of arthroplasty surgeons. Improved awareness and understanding of the baseline demographic differences between these patients is paramount. Recognition of the increased complication rates grants the opportunity to improve their orthopaedic care through preoperative and multidisciplinary management.

The Relationship Between Medicaid Coverage and Outcomes Following Total Knee Arthroplasty: A Systematic Review

BACKGROUND

Access to elective total knee arthroplasty is important in the treatment of end-stage arthritis, and numerous initiatives, including Medicaid expansion, have sought to improve patients' ability to undergo this procedure. However, despite this, the role of Medicaid insurance in patient outcomes remains unclear. The purpose of this study was to perform a systematic review of the literature to explore the relationship between preoperative Medicaid insurance status and outcomes following primary total knee arthroplasty.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies examining outcomes in patients who had Medicaid and were undergoing total knee arthroplasty. Studies including complex revision operations or less common indications for total knee arthroplasty were excluded. Data on insurance status, postoperative complications, length of stay, readmissions, and subsequent revision surgical procedures were collected for each article.

RESULTS

A total of 13 studies showing 6.18 million patients undergoing total knee arthroplasty were included in the qualitative synthesis. Seven analyses described an important association between Medicaid coverage and short-term readmissions, and 2 analyses showed a relationship between Medicaid and prolonged length of stay. However, the included studies did not describe a significant association between Medicaid and postoperative mortality or revision rates.

CONCLUSIONS

Patients with Medicaid undergoing total knee arthroplasty may be more likely to experience an increased length of stay and to be readmitted postoperatively. The unique factors associated with these patients may help to inform customized perioperative surveillance and optimization to improve outcomes in this group.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Undetectable Hepatitis C Viral Load Is Associated With Improved Outcomes Following Total Joint Arthroplasty

BACKGROUND

Previous reports establish that infection with hepatitis C virus (HCV) predisposes total joint arthroplasty (TJA) recipients to poor postoperative outcomes. The purpose of the present study is to assess whether variation in HCV VL influences perioperative outcomes following TJA.

METHODS

A multicenter retrospective review of all patients diagnosed with HCV who underwent primary TJA between January 2005 and April 2018 was conducted. Patients were stratified into 2 cohorts: (1) patients with an undetectable VL (U-VL) and (2) patients with a detectable VL (D-VL). Kaplan-Meier survivorship analysis was calculated with revision TJA as the end point. Subanalysis on the VL profile was done.

RESULTS

A total of 289 TJAs were included (U-VL:118 TJAs; D-VL:171 TJAs). Patients in the D-VL cohort had longer operative times (133.9 vs 109.2 minutes), higher intraoperative blood loss (298.4 vs 219.5 mL), longer inpatient hospital stays (4.0 vs 2.9 days), more postoperative infections (11.7% vs 4.2%), and an increased risk for revision TJA (12.9% vs 5.1%). Kaplan-Meier demonstrated that the U-VL cohort trended toward better survivorship (P = .17). On subanalysis of low and high VL, no difference in outcomes was appreciated.

CONCLUSION

TJA recipients with a detectable HCV VL have longer operative times, experience more intraoperative blood loss, have longer hospital length of stay, and are more likely to experience infection and require revision TJA. The blood loss, hospital length of stay, and revision rate findings should be interpreted with caution, however, as there are confounding factors. Our findings suggest that HCV VL is a modifiable risk factor that, can reduce the risk of infection and revision surgery. Additionally, serum HCV VL was not correlated with outcomes.

Outcome of total hip and knee arthroplasty in HIV-infected patients: A systematic review

Significant advances in the treatment of Human Immunodeficiency Virus (HIV) have occurred in recent times, with life expectancy now approaching the normal population. Therefore, patients with HIV will increasingly be undergoing joint replacement in the future, however concerns remain regarding the complications and outcome in this patient cohort. The aim was to assess the outcome of total hip and knee arthroplasty in HIV-infected patients. A systematic search of the literature using MOOSE reporting guidelines was performed to assess the outcome of hip and knee arthroplasty in HIV-infected patients. The primary outcome was infection. Secondary outcome was all-cause revision. The search yielded 552 results, of which 19 met the inclusion criteria, comprising 5.819.412 joint replacements. The overall quality of the studies was poor with significant heterogeneity between the studies. Infection and revision appeared to be more likely to occur in HIV positive patients compared to HIV negative patients. A subgroup analysis of four studies revealed a risk ratio of 3.31 and 2.25 for increase in infection and revision respectively in HIV positive patients. This systematic review and meta-analysis demonstrates an increased risk of infection and revision in HIV infected patients undergoing total hip and knee arthroplasty. However, these findings are based on poor quality evidence in a limited number of studies and need to be interpreted with caution. Further research should concentrate on large, well-designed, prospective studies, that control for co-morbidities and employ standardised outcome measures to allow for direct comparison.