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The incidence and natural history of osteonecrosis in HIV-infected adults
Caryn G Morse1, JoAnn M Mican, Elizabeth C Jones
1Critical Care Medicine Department, NIH Clinical Center, Bethesda, Maryland 20892-1662, USA. cmorse@mail.nih.gov
Insights
Human immunodeficiency virus (HIV) patients face a significantly higher risk of osteonecrosis. This study tracked HIV patients, revealing slower disease progression in asymptomatic individuals and a high rate of hip replacement in symptomatic cases.
Area of Science:
- Orthopedics
- Infectious Diseases
- Radiology
Background:
- Osteonecrosis is a recognized complication in human immunodeficiency virus (HIV) infection, yet its natural history remains poorly understood.
- Previous research identified a 4.4% prevalence of hip osteonecrosis via MRI in asymptomatic HIV patients.
- This study aimed to establish the incidence of new osteonecrosis cases and describe the disease's progression in HIV-infected individuals.
Purpose of the Study:
- To determine the incidence of newly diagnosed osteonecrosis in a cohort of HIV-infected patients.
- To describe the natural history and progression of osteonecrosis in this population.
- To compare the outcomes of asymptomatic versus symptomatic osteonecrosis.
Main Methods:
- Follow-up magnetic resonance imaging (MRI) was performed on asymptomatic HIV-infected patients previously found to have no hip osteonecrosis.
- Patients diagnosed with osteonecrosis (asymptomatic or symptomatic) were enrolled in a natural history study.
- Serial MRIs and physiotherapy assessments were utilized to monitor disease progression.
Main Results:
- The incidence of femoral head osteonecrosis was 0.65 cases per 100 person-years, with symptomatic hip osteonecrosis occurring at 0.26 cases per 100 person-years.
- Symptomatic patients showed significantly greater femoral head involvement and progression to total hip replacement (59%) compared to asymptomatic patients (11%).
- Bilateral femoral head involvement was common in symptomatic cases (18/22), with 7 patients experiencing osteonecrosis in other bones.
Conclusions:
- HIV-infected individuals exhibit a substantially elevated risk (approximately 100-fold) of developing osteonecrosis compared to the general population.
- Osteonecrosis progression is demonstrably slower in asymptomatic HIV patients than in symptomatic ones.
- The high rate of total hip replacement in symptomatic patients underscores the urgent need for research into preventive and therapeutic strategies.
Background:
Osteonecrosis is increasingly recognized as a debilitating complication of human immunodeficiency virus (HIV) infection, but the natural history has not been well described. We previously documented a high prevalence (4.4%) of magnetic resonance imaging (MRI)-documented osteonecrosis of the hip in a cohort of 339 asymptomatic HIV-infected patients. The present study was designed to determine the incidence of newly diagnosed osteonecrosis in this cohort and to describe the natural history of osteonecrosis in HIV-infected patients.
Methods:
Asymptomatic HIV-infected patients with a previous hip MRI negative for osteonecrosis underwent follow-up MRI. Patients with asymptomatic or symptomatic osteonecrosis were enrolled in a natural history study, which included serial MRIs and a physiotherapy follow-up.
Results:
Two hundred thirty-nine patients underwent a second MRI a median of 23 months after the initial MRI. Osteonecrosis of the femoral head was diagnosed in 3 patients (incidence, 0.65 cases per 100 person-years). During the period of January 1999 through April 2006, symptomatic hip osteonecrosis developed in 13 clinic patients (incidence, 0.26 cases per 100 person-years). Among 22 patients enrolled with symptomatic hip osteonecrosis, 18 had bilateral involvement of the femoral heads, and 7 had osteonecrosis involving other bones. Two (11%) of 18 asymptomatic patients and 13 (59%) of 22 symptomatic patients underwent total hip replacement. The percentage of involvement of the weight-bearing surface of the femoral head and the rate of progression to total hip replacement was significantly greater (P<.001) in symptomatic patients than in asymptomatic patients.
Conclusions:
HIV-infected patients are at approximately 100-fold greater risk of developing osteonecrosis than the general population. Disease progression is slower in asymptomatic patients than in symptomatic patients. Given the high frequency of total hip replacement in symptomatic patients, studies to assess preventive and treatment strategies are essential.
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