High Prevalence of Osteonecrosis of the Femoral Head in HIV-Infected Adults

  1. Kirk D. Miller, MD;
  2. Henry Masur, MD;
  3. Elizabeth C. Jones, MD, MPH;
  4. Galen O. Joe, MD;
  5. Margaret E. Rick, MD;
  6. Grace G. Kelly, MSS;
  7. JoAnn M. Mican, MD;
  8. Shuying Liu, BSN;
  9. Lynn H. Gerber, MD;
  10. William C. Blackwelder, PhD;
  11. Judith Falloon, MD;
  12. Richard T. Davey, Jr., MD;
  13. Michael A. Polis, MD, MPH;
  14. Robert E. Walker, MD;
  15. H. Clifford Lane, MD; and
  16. Joseph A. Kovacs, MD
  1. From the Clinical Center and National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland.

    Abstract

    Background: Osteonecrosis has been reported to occur occasionally among HIV-infected patients. The diagnosis of symptomatic osteonecrosis of the hip in two of the authors' patients, together with reports from community physicians, raised a concern that the prevalence of osteonecrosis is increasing.

    Objective: To determine the prevalence of osteonecrosis of the hip in asymptomatic HIV-infected patients and to identify potential risk factors associated with osteonecrosis.

    Design: Survey and comparison study.

    Setting: The Clinical Center of the U.S. National Institutes of Health.

    Participants: 339 asymptomatic HIV-infected adults (of 364 asked to participate) and 118 age- and sex-matched HIV-negative volunteers enrolled between 1 June and 15 December 1999.

    Measurements: Osteonecrosis of the hip, as documented by magnetic resonance imaging. Data from clinic records and a patient questionnaire administered before magnetic resonance imaging were used in an analysis of risk factors. A subset of patients was evaluated for hypercoagulable state.

    Results: Fifteen (4.4% [95% CI, 2.5% to 7.2%]) of 339 HIV-infected participants had osteonecrosis lesions on magnetic resonance imaging, and no HIV-negative participants had similar lesions. Among HIV-infected participants, osteonecrosis occurred more frequently in those who used systemic corticosteroids, lipid-lowering agents, or testosterone; those who exercised routinely by bodybuilding; and those who had detectable levels of anticardiolipin antibodies.

    Conclusions: Patients infected with HIV have an unexpectedly high occurrence of osteonecrosis of the hip. Although screening asymptomatic patients is not warranted, HIV-infected patients with persistent groin or hip pain should be evaluated for this debilitating complication.

    Article and Author Information

    • Acknowledgments: The authors thank the patients and volunteers for their participation; Catherine Decker, MD, of the National Naval Medical Center and Florentino Merced-Galindez, RN, of the National Cancer Institute for referring patients; Andrew Dwyer, MD, for assistance with interpreting MRI scans; and Brian Evans, MD, for sharing his orthopedic experience. In addition, the authors thank Susan Vogel, RN, and Doreen Chaitt, RN, for assistance with data collection and Chris Bechtel, RN, Barbara Hahn, RN, and Diane Rock, RN, for recruitment efforts. They also thank the staff of the National Institute of Allergy and Infectious Diseases and Critical Care Medicine department for patient care and the radiology technicians who performed the imaging.

    • Requests for Single Reprints: Joseph A. Kovacs, MD, National Institutes of Health, Building 10, Room 7D43, MSC1662, Bethesda, MD 20892-1662; e-mail, jkovacs{at}niaid.nih.gov.

    • Current Author Addresses: Drs. Miller, Masur, and Kovacs: Critical Care Medicine Department, Clinical Center, Building 10, Room 7D43, MSC1662, National Institutes of Health, Bethesda, MD 20892-1662.

    • Dr. Jones: Diagnostic Radiology Department, Clinical Center, Building 10, Room 1C660, MSC1182, National Institutes of Health, Bethesda, MD 20892-1182.

    • Drs. Joe and Gerber: Rehabilitation Medicine Department, Clinical Center, Building 10, Room 6S235, MSC1604, National Institutes of Health, Bethesda, MD 20892-1604.

    • Dr. Rick: Department of Laboratory Medicine, Clinical Center, Building 10, Room 2C390, National Institutes of Health, Bethesda, MD 20892.

    • Ms. Kelly: Critical Care Medicine Department, Clinical Center, Building 10, Room 8C403, MSC1756, National Institutes of Health, Bethesda, MD 20892-1756.

    • Dr. Mican: Office of the Clinical Director, National Institute of Allergy and Infectious Diseases, Building 10, Room 11S231, MSC 1876, National Institutes of Health, Bethesda, MD 20892-1876.

    • Ms. Liu: Department of Nursing, Clinical Center, Building 10, Room 11C429, National Institutes of Health, Bethesda, MD 20892.

    • Dr. Blackwelder: 8613 Hempstead Avenue, Bethesda, MD 20817-6711.

    • Drs. Falloon, Davey, and Polis: Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, Building 10, Room 11C103, National Institutes of Health, Bethesda, MD 20892-1880.

    • Dr. Walker: Aviron, 297 North Bernardo Avenue, Mountain View, CA 94043.

    • Dr. Lane: Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, Building 10, Room 11S231, MSC 1876, National Institutes of Health, Bethesda, MD 20892-1876.

    • Author Contributions: Conception and design: K.D. Miller, H. Masur, E.C. Jones, G.O. Joe, M.E. Rick, J.M. Mican, L.H. Gerber, J. Falloon, R.T. Davey, M.A. Polis, H.C. Lane, J.A. Kovacs.

    • Analysis and interpretation of the data: K.D. Miller, H. Masur, E.C. Jones, G.O. Joe, M.E. Rick, L.H. Gerber, W.C. Blackwelder, J. Falloon, R.T. Davey, M.A. Polis, R.E. Walker, J.A. Kovacs.

    • Drafting of the article: K.D. Miller, G.O. Joe, M.E. Rick, G.G. Kelly, W.C. Blackwelder, R.T. Davey, M.A. Polis, J.A. Kovacs.

    • Critical revision of the article for important intellectual content: K.D. Miller, H. Masur, L.H. Gerber, J. Falloon, R.T. Davey, M.A. Polis, R.E. Walker, J.A. Kovacs.

    • Final approval of the article: K.D. Miller, H. Masur, G.O. Joe, L.H. Gerber, J. Falloon, R.T. Davey, M.A. Polis, R.E. Walker, J.A. Kovacs.

    • Provision of study materials or patients: K.D. Miller, H. Masur, J.M. Mican, S. Liu, J. Falloon, R.T. Davey, M.A. Polis, J.A. Kovacs.

    • Statistical expertise: W.C. Blackwelder.

    • Obtaining of funding: H. Masur, J. Falloon.

    • Administrative, technical, or logistic support: G.G. Kelly, S. Liu, R.T. Davey.

    • Collection and assembly of data: K.D. Miller, G.O. Joe, G.G. Kelly, S. Liu, L.H. Gerber, R.T. Davey, M.A. Polis.

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    1. Ann Intern Med July 2, 2002 vol. 137 no. 1 17-25
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