Hiv in orthopaedics

HIV
IN
ORTHOPAEDICS
 DR MAULIK T PATEL
Department of Orthopedics,
Meenakshi mission hospital

INTRODUCTION
 ACQUIRED IMMUNODEFICIENCY
SYNDROME
 HUMAN IMMUNODEFICIENCY
VIRUS
 PANDEMIC
 NO CURE YET

STATISTICS
 Deaths Annually: 14,802
(1999)
Death Rate: 5.4 deaths per
100,000 population (1999)

STATISTICS
 Number of Cases: 20,550 (January-
June 2000)
Hospital Discharges for Patients with
HIV Diagnosis: 180,000 (1999)
Number of Days of Care for Patients
with HIV Diagnosis: 1,310,000
(1999)
Average Length of Hospital Stay: 7.3
days (1999)

INTRODUCTION
 DISABILITY OR LIFE
THREATENING ILLNESS
CAUSED BY HIV CHARACTERISED
BY HIV ENCEPHALOPATHY,HIV
WASTING SYNDROME, DISEASES
DUE TO IMMUNODEFICIENCY IN A
PERSON WITH LAB EVIDENCE OF
HIV INFECTION OR WITHOUT
OTHER CAUSES OF
IMMUNODEFICIENCY

DEFINITION (1993) CDC
 ANY HIV INFECTED INDIVIDUAL
WITH A CD4+ T CELL COUNT OF
LESS THAN 200/µL HAS AIDS
REGARDLESS OF THE PRESENCE OF
SYMPTOMS OR OPPORTUNISTIC
DISEASE

CLASSIFICATION
Clinical
categories
Cd4 count
A
Asymptomat
ic a/c hiv or
pgl
B
Symptoma
tic not
AorC
C
Aids
indicator
conditions
>500 A1 B1 C1
200-499 A2 B2 C2
<200 A3 B3 C3

INTRODUCTION
 FIRST REPORTED IN 1981 IN USA
 GRID VIRUS
 LUC MONTAGNIER 1983 , PARIS

HUMAN
IMMUNODEFICIENCY
VIRUS
 REVERSE TRANSCRIPTASE ENZYME
 INFECTION LIFE LONG
 ASYMPTOMATIC FOR MANY YEARS
 VIRUS IS FRAGILE- DESTROYED BY BOILING
FOR ONE SECOND, 1% BLEACH ,70%
ETHANOL, 2% GLUTERALDEHYDE,5%
FORMALDEHYDE, 1% CHLORINE-SODIUM
HYPOCHLORITE, 3% H2O2

MODES OF
TRANSMISSION
 SEXUAL INTERCOURSE
 TRANSFUSION
 SYRINGES & NEEDLES
 PRENATAL & PERINATAL
 ORGAN TRANSPLANTS
 DIALYSIS

MODES OF
TRANSMISSION
HIV IS NOT
TRANSMITTED BY
SOCIAL CONTACTS

LIFE CYCLE
HIV INFECTS A
PERSON IN MANY
WAYS AND………

LIFE CYCLE
 IMMUNE SYSTEM
FIGHTS BACK IN THREE
WAYS. WITH………….

LIFE CYCLE
THE DEFENCE IS
COORDINATED BY…

HIV ATTACHES TO CD4 RECEPTOR ON T CELLS

LIFE CYCLE
INSIDE THE CELL
IT IS SAFE ……

VIRAL RNA IS
TRANSCRIBED INTO DNA

LIFE CYCLE
 AFTER A WHILE THE VIRUS
COMES OUT OF HIDING AND
REPRODUCE..

THE DNA IS TRANSCRIBED
INTO MANY COPIES OF RNA

RNA PRODUSE PROTIENS OF
THE VIRUS

PROTIENS ARE THEN CUT INTO USABLE PIECES AND
PACKAGED WITH RNA

LIFE CYCLE
THE NEW VIRUSES
THUS PRODUCED …..

LIFE CYCLE
 THESE THEN GO ON TO INFECT
OTHER T CELLS THUS WEAKENING
THE IMMUNE SYSTEM
 THIS WILL ENABLE THE ENTRY OF
OTHER PATHOGENS INTO THE
BODY

PATHOGENESIS
 PRIMARY HIV INFECTION,INITIAL
VIREMIA & DISSEMINATION OF
VIRUS
 ESTABLISHMENT OF CHRONIC &
PERSISTENT INFECTION
 ADVANCED HIV DISEASE

PATHOGENESIS
 ROLE OF LYMPHOID ORGANS
 ROLE OF CELLULAR ACTIVATION
 ROLE OF APOPTOSIS
 SUPER ANTIGENS
 AUTOIMMUNE PHENOMENA
 COFACTORS
 CYTOKINE NETWORK

IMMUNE RESPONSE
 HUMERAL
antibodies to p24 p17 & p55
antibodies to gp160 gp 120 gp88
gp41
 CELLULAR

DIAGNOSIS
 SCREENING TEST – ELISA
 CONFIRMATORY - WESTERN -
BLOT
 DIRECT HIV DETECTION
P24 AG CAPTURE ASSAY
HIV RNA BY PCR

CLINICAL
MANIFESTATIONS
 THE ACUTE HIV SYNDROME
 ASYMPTOMATIC STAGE
 EARLY SYMPTOMATIC
 NEUROLOGIC DISEASE
 OPPORTUNISTIC INFECTIONS
 NEOPLASTIC DISEASE

MANAGEMENT
PREVENTION IS
BETTER THAN
CURE

MANAGEMENT
 HEALTH CARE WORKER
RISK OF INFECTION WITH A
HOLLOW BORE NEEDLE PRICK –
0.3%
RISK WITH SUTURE NEEDLE IS
LESS

PREVENTION
 REGULAR HAND WASHING
 COVER WOUNDS/SKIN LESIONS
 PROTECT EYES , MOUTH & NOSE
 NEVER TRANSFER SHARP OBJECTS
DIRECTLY
 NEVER RECAP A NEEDLE , PROPER
DISPOSAL OF SHARP OBJECTS
 CONSIDER EVERY PT AS A POTENTIAL
RISK – STICK TO UNIVERSAL
PRECAUTIONS

PREVENTION
 DOUBLE GLOVES
 PLASTIC APRON
 WATER RESISTANT SHOE COVER
 FACE SHIELD OR GOGGLES

EXPOSURE
 SPLASH ON THE SKIN
 WASH THOROUGHLY WITH SOAP
& WATER
 DIP HANDS IN UNDILUTED
SAVLON FOR 15 SEC.

EXPOSURE
 NEEDLE STICK INJURY
 LET THE WOUND BLEED
FREELY WITHOUT PRESSING IT
 THOROUGHLY WASH
 DIP HANDS IN UNDILUTED SAVLON
FOR 15 SEC.
 TEST THE PT FOR HIV
 TEST SELF AT 3 , 12 , & 24
WEEKS

EXPOSURE
 IF PT IS NEGATIVE FOLLOW UP AT
3 , 12 , 24 WEEKS
 TAKE THE HISTORY OF THE PT-
HIGH RISK BEHAVIOR
 USE CONDOMS WITH THE PARTNER
FOR 6 MONTHS

POST EXPOSURE DRUG
PROPHYLAXIS
 AZIDOTHYMIDINE
 WITHIN ONE HOUR OF EXPOSURE
 200mg q4h FOR 72 HRS
 100 – 200mg Q4H FOR 25 DAYS

STRATEGIES
 HELP THE IMMUNE SYSTEM
VACCINE

STRATEGIES
 Problems with this approach.
 Scientists have to make sure the vaccine itself
doesn't make people ill.
 HIV is constantly changing, so the defenses
stimulated by a vaccine might not be effective in
fighting the actual virus.
 And if even a single virus escapes by hiding out
inside a cell, it could go on to make thousands
of copies of itself.

STRATEGIES
 ARTIFICIAL DECOY CD4 UNITS CAN
BE GIVEN
 HIV WILL ATTACH TO THESE
INSTEAD OF T CELLS

STRATEGIES
 USE OF DRUGS THAT LOOK LIKE
BUILDING BLOCKS OF DNA
 PREVENT CONVERTION OF VIRAL
RNA INTO DNA

 HIV is constantly changing, and
eventually it is no longer tricked by
these faulty building blocks. HIV
becomes resistant to these drugs, and
the life cycle continues the same as
before. Another problem is that these
drugs can damage non-infected cells
which also need to make DNA to
reproduce.

STRATEGIES
 STOPPING THE PRODUCTION OF
VIRAL PROTEINS WITH DRUGS
 PREVENTION OF SPLICING

STRATEGIES
 BOOST THE IMMUNE SYSTEM
OF THE PT
 TREAT OPPORTUNISTIC
INFECTIONS

ORTHOPAEDIC
PROBLEMS
 RHEUMATOID ARTHRITIS
 ARTHRALGIAS
 REACTIVE ARTHRITIS
 AIDS ASSOCIATED ARTHROPATHY
 FIBROMYALGIA
 SEPTIC ARTHRITIS

ORTHOPAEDIC
PROBLEMS
 RHEUMATOID ARTHRITIS-
AMELIORATED IN SPITE OF HIGH
LEVELS OF ANTI PHOSPHOLIPID
ABS&ANTINUCLEAR ABS.

REACTIVE ARTHRITIS
 33% AIDS PTS HAVE
ARTHRALGIAS
 5-10% REITER’S / PSORIATIC

AIDS ASSOCIATED
ARTHROPATHY
 JOINT PROBLEMS WITH NO CAUSE
 SUBACUTE OLIGOARTHRITIS
 1 – 6 WEEKS
 LASTS 6 WKS – 6 MONTHS
 LARGE JTS-KNEE / ANKLE

AIDS ASSOCIATED
ARTHROPATHY
 NONEROSIVE
 X-RAY NONREVEALING
 RESPOND TO INTRA ARTICULAR
STEROID

AIDS ASSOCIATED
ARTHROPATHY
 PAINFUL ARTICULAR SYNDROME-
10% PTS
A/C SEVERE,SHARP PAIN
KNEE,ELBOW,SHOULDER
LASTS 2 – 24 HRS
NARCOTIC ANALGESICS

FIBROMYALGIA
 WIDESPREAD
MUSCULOSKELETAL PAIN OF 3
MONTHS
 11 OF 18 TENDER POINTS

SEPTIC ARTHRITIS
 RARE
 FUNGAL-
CRYPTOCOCCUS,SPOROTHRIX
 MYCOBACTERIAL-M.HEMOPHILUM
 COMMON IN HAEMOPHILIACS

ORTHOPAEDIC
PROBLEMS
 SURGERY MAY PROMOTE
CLINICAL AIDS IN SEROPOSITIVE
PTS

AIDS & ORTHOPAEDIC
SURGEON
IGNORANCE BREEDS
FEAR

FRACTURES
 CLOSED # HEAL NORMALLY WITH
CONSERVATIVE TREATMENT
 HIGH INFECTION RATE WITH ORIF
 OPEN # -- INFECTION & NONUNION

COLD SURGERY
 INCREASED RISK OF SEPSIS
 RELATED TO STAGE OF AIDS

TUBERCULOSIS
 DUAL EPIDEMIC
 HIV & TB ARE SYNERGISTIC
 WASTING DISEASE , NIGHT SWEATS
 REST , FOOD , DRUGS
 PROGNOSIS POOR

OTHER INFECTIONS
 TROPICAL PYOMYOSITIS
 HEMATOGENOUS OSTEOMYELITIS
 LATE INFECTION OF IMPLANTS

 RISK OF TRANSMISSION OF HIV
FROM PT TO SURGEON IS
SMALL
 FROM SURGEON TO PT IS EVEN
LESS
 RISK ACCUMULATE OVER TIME

 PUT LARGER INCISION
 OPERATE BY SIGHT THAN
FEEL
 NO SHARP INSTRUMENT
SHOULD BE HANDED
DIRECTLY

 “WE MUST HAVE OPERATED ON
MANY HIV POSITIVE PTS BEFORE
THE DANGERS WERE RECOGNISED
OR PRECAUTIONS PUT IN PLACE,
BUT SENIOR SURGEONS HAVE NOT
BEEN DYING OF HIV INFECTIONS.”
- J.E.JELLIS

 Increased Abdominal Visceral Fat Is
Associated With Reduced Bone Density in
HIV-Infected Men With Lipodystrophy
 disrupted fat metabolism may account for HIV-
related osteopenia.
 abnormal marrow or whole body fat metabolism
may affect bone cell differentiation or the
marrow cytokine environment in people with
HIV-related lipodystrophy."

ANTIRETROVIRAL
THERAPY
 NUCLEOSIDE ANALOGUES
 ZIDOVUDINE
 DIDANOSINE
 ZALCITABINE
 STAVUDINE
 LAMIVUDINE

ANTIRETROVIRAL
THERAPY
 NONNUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITORS
 NEVIRAPINE
 DELAVIRDINE

ANTIRETROVIRAL
THERAPY
 PROTEASE INHIBITORS
 SAQUINAVIR
 RITONAVIR
 INDINAVIR
 NELFINAVIR

ANTIRETROVIRAL
THERAPY
 TRIPPLE THERAPY
 TWO NUCLEOSIDES & ONE
PROTEASE INHIBITOR

Hiv in orthopaedics

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