Correspondence

Osteonecrosis of the Femoral Head:

Evaluation and Treatment

Dr. van der Jagt or an immediate

family member is a member of
a speakers bureau or has made paid
presentations on behalf of and serves
as a paid consultant to Boehringer
Ingelheim, and serves as a board
member, owner, officer, or committee
member of the South African
Orthopaedic Association and the
South African Society for Thrombosis
and Haemostatis. Dr. Mokete or an
immediate family member has
received research or institutional
support from Biomet and Smith &
Nephew. Dr. Lieberman or an
immediate family member has
received royalties from DePuy; serves
as a paid consultant to Arthrex and
DePuy; has stock or stock options
held in Hip Innovation Technology;
has received research or institutional
support from Arthrex; and serves as
board member, owner, officer, or
committee member of the American
Academy of Orthopaedic Surgeons.
Neither of the following authors nor
any immediate family member has
received anything of value from or has
stock or stock options held in
a commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Pietrzak and
Dr. Zalavras.
http://dx.doi.org/10.5435/
JAAOS-D-14-00431

To the Editor: We would like

to commend Drs. Zalavras and
Lieberman for their excellent
review article on osteonecrosis of
the hip.1 We do need, however, to
highlight the massive disease burden that many less developed parts
of the world are subjected to as
a consequence of HIV and its
management. The high incidence of
osteonecrosis of the hip as a result
of HIV infection is well documented.2,3 In the past, the limited
lifespan of these patients meant
that the orthopaedic management
load was limited.
The introduction of effective disease control measures, especially
anti-retroviral therapy (ART), has
resulted in these patients surviving
relatively HIV-symptom free and
with a near-normal life expectancy.
This increased survivorship in
respect of HIV infections, however,
has allowed the disease-related
sequela osteonecrosis to become
common place. This is further
compounded by the osteonecrosis
resulting directly from the treatment with ART,4 in itself essential
to keep the progression of HIV to
AIDS at bay.
At the Johannesburg, South Africa,
Complex of Academic Hospitals, we
have experienced a dramatic rise in
osteonecrosis of the hip, usually in
young people who are HIV positive
and on ART. Fully 25% of all the hip
replacements currently done at our
hospitals for end-stage osteonecrosis
are now due to HIV/ART. This
additional burden on our stretched
resources is over and above the routine demand for joint arthroplasties
for degenerative and other joint disease. Actuarial calculations project
that within 10 years, we may need to

perform more than an additional

1,000 hip replacements for HIV/
ART-related osteonecrosis at the
Johannesburg Complex of Academic
Hospitals alone.5
We are sure that the review by
these authors1 would have been
enhanced by some mention of HIV
and ART in the etiology and
pathogenesis of osteonecrosis of
the hip.
Dick van der Jagt,
MBBch, FCS(SA) Orth
Lipalo Mokete, MBBch,
FCS(SA) Orth
Jurek Pietrzak, MBBch,
FCS(SA) Orth
Johannesburg, South Africa
The Authors Reply: We would like
to thank Drs. van der Jagt,
Mokete, and Pietrzak for finding
our review excellent and for their
important comment. We agree
that there is an increased incidence
of osteonecrosis in HIV-infected
patients. As these authors report,
the increased survivorship of these
patients has led to an increased
number of joint arthroplasty
procedures and a considerable
burden on available healthcare
resources, especially in developing
countries.
However, a direct link between antiretroviral therapy (ART) and osteonecrosis in HIV-infected patients
has not been established, and for
this reason, we did not include this
in the etiology and pathogenesis section. Several case-control studies
evaluating risk factors for the development of osteonecrosis in HIVinfected patients have not shown an
association with ART.2,3,6-9 Instead,
they documented the significantly

February 2015, Vol 23, No 2

Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

69

Correspondence

increased presence of already

established risk factors, such as corticosteroid use,2,3,7,9 coagulopathy,3
hyperlipidemia,3,4 and alcohol consumption,9 in HIV-infected patients
who developed osteonecrosis compared with HIV-infected patients who
did not develop the disease. Our suspicion is that there is some type of
association, but further study of this
issue is needed to define it.
Thank you again for highlighting
the important problem of osteonecrosis in HIV-infected patients. A high
index of suspicion for osteonecrosis in
these patients may lead to diagnosis at
an earlier stage and treatment with
a femoral head-sparing procedure,
thereby potentially decreasing the
burden of the disease.

70

Charalampos G. Zalavras, MD
Jay R. Lieberman, MD
Los Angeles, CA

5. Mokete L, Mohideen M, Pietrzak JR, van der

Jagt DR: Projections for elective total hip
replacement for osteonecrosis of the hip in
HIV: is South Africa adequately prepared?
Bloemfontein, South Africa, S Afr Orthop
Congr, 2014, p 113.
6. Scribner AN, Troia-Cancio PV, Cox BA, et al:
Osteonecrosis in HIV: A case-control study.
J Acquir Immune Defic Syndr 2000;25(1):19-25.

References
1. Zalavras CG, Lieberman JR: Osteonecrosis of
the femoral head: Evaluation and treatment.
J Am Acad Orthop Surg 2014;22(7):455-464.
2. Keruly JC, Chaisson RE, Moore RD:
Increasing incidence of avascular necrosis of the
hip in HIV-infected patients. J Acquir Immune
Defic Syndr 2001;28(1):101-102.
3. Miller KD, Masur H, Jones EC, et al: High
prevalence of osteonecrosis of the femoral
head in HIV-infected adults. Ann Intern Med
2002;137(1):17-25.
4. Matos MA, Alencar RW, Matos SS:
Avascular necrosis of the femoral head in
HIV infected patients. Braz J Infect Dis
2007;11(1):31-34.

7. Glesby MJ, Hoover DR, Vaamonde CM:

Osteonecrosis in patients infected with human
immunodeficiency virus: A case-control study.
J Infect Dis 2001;184(4):519-523.
8. Hasse B, Ledergerber B, Egger M, et al; Swiss
HIV Cohort Study: Antiretroviral treatment and
osteonecrosis in patients of the Swiss HIV
Cohort Study: A nested case-control study. AIDS
Res Hum Retroviruses 2004;20(9):909-915.
9. Lawson-Ayayi S, Bonnet F, Bernardin E, et al;
Groupe dEpidmiologie Clinique du SIDA en
Aquitaine: Avascular necrosis in HIV-infected
patients: A case-control study from the
Aquitaine Cohort, 1997-2002, France. Clin
Infect Dis 2005;40(8):1188-1193.

Journal of the American Academy of Orthopaedic Surgeons

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