Total Joint Arthroplasty in Immunocompromised Patients

A Matched Pair Analysis for Comorbidities

Morteza Meftah, MD; Grace Plassche, BS; Ariel Silverman, BS; Peter B. White, BS; Ira H. Kirschenbaum, MD


Curr Orthop Pract. 2019;30(3):246-249. 

In This Article

Abstract and Introduction


Background: The prevalence and demand for total joint arthroplasty (TJA) in patients with human immunodeficiency virus (HIV) and hepatitis C (HCV) have steadily increased. However, the relationship between these immunocompromising viruses and perioperative complications such as postoperative infection has yet to be fully established.

Methods: TJA was performed in 109 immunocompromised (IC) patients (50 THAs and 59 TKAs) between 2008 and 2014. Patients were matched based on sex, age, body mass index, and operation (TKA vs. THA) to patients who were nonimmunocompromised (N-IC). A cohort of 66 IC patients were also matched with 66 N-IC based on medical comorbidities to assess for medical comorbidities that may increase the risk of infection.

Results: The overall complication rate in the IC group and N-IC groups was 20% (22 patients) and 14.6% (16 patients), respectively, which was not statistically significant (P=0.34). There were no differences between the two groups in the incidence of deep (n=6; 5.5% vs. n=3; 2.7%; P=0.36) or superficial infections (n=4; 2.1% vs. n=1; 0.9%; P=0.50), or re-admissions (n=12; 11% vs. 14; 12.8%; P=0.80). However, there was a significant difference for reoperation (16 vs. 6, P=0.04). When data were adjusted for confounding factors for complications, matched for comorbidities, the rate of infection and reoperation were 7.5% and 4.5% in IC and 9% and 6% in N-IC groups, respectively, which were not statistically significant.

Conclusions: IC patients were not at a significant increased risk for perioperative complications, postoperative infections, or readmissions, but they were at higher risk of reoperation.


In recent time, significant advances have been made in the treatment of immunocompromising viruses such as human immunodeficiency viruses (HIV) and hepatitis C (HCV).[1–3] Highly active antiretroviral therapy (HAART) and direct antivirals have revolutionized the morbidities associated with HIV and HCV, respectively.[1,2] Consequently, the prevalence of these conditions is rapidly increasing. According to the Center for Disease Control, the prevalence of these conditions is estimated to be 1.1 million people in the United States living with HIV and 2.7 to 3.9 million living with chronic HCV.[4–6] As the life expectancy of this population also is growing,[1,3,6] the demand for total hip (THA) and knee arthroplasty (TKA) also is increasing.[7]

One of the concerns of TJA in this population is that they may be at an increased risk for adverse complications. Although several studies have shown that patients with HIV are at an increased risk for perioperative complications, most notably infections,[8–12] other studies have found that the presence of these viruses is not an independent risk factor for postoperative infection.[13–15] Similarly, there is conflicting evidence regarding the relationship of HCV with postoperative complications and infection.[16–21] Hence, the relationship between immunocompromising viruses and adverse postoperative complications, especially in the setting of HIV and HCV is yet to be fully established.

A preliminary study at our institution showed an exceptionally high rate of immunocompromised patients undergoing joint arthroplasty in this region. Therefore, the purpose of this study was to evaluate the (1) incidence of perioperative infection and overall complications, (2) rate of readmissions, reoperations, and revision surgeries, and (3) identify any medical major comorbidities that may increase the risk of perioperative complications.