High Prevalence of Osteonecrosis of the Femoral Head in HIV-Infected Adults
Reported by Jules Levin
This is an official publication of data that had been reported previously at
science conferences. The authors report a high rate of symptomless
osteonecrosis as measured by MRI in HIV+ persons. But the authors conclude
they cannot determine if this high rate is due to HIV or by some of the drugs
taken and intense bodybuilding exercises performed by some of the study
participants who had HIV infection. Osteonecrosis was more frequent among the
HIV-infected persons who had used steroids, lipid-lowering drugs, or
testosterone and among those who routinely did bodybuilding exercises. None
of the adults without HIV infection were found to have osteonecrosis.
Although this study did not involve patients with hip pain, osteonecrosis
should probably be considered in HIV-infected persons who begin to have pain
and problems with their hips.|
Kirk D. Miller, MD; Henry Masur, MD; Elizabeth C. Jones, MD, MPH; Galen O.
Margaret E. Rick, MD; Grace G. Kelly, MSS; JoAnn M. Mican, MD; Shuying Liu,
Lynn H. Gerber, MD; William C. Blackwelder, PhD; Judith Falloon, MD; Richard
T. Davey, MD; Michael A. Polis, MD, MPH; Robert E. Walker, MD; H. Clifford
Lane, MD; and Joseph A. Kovacs, MD
Ann Intern Med. 2002;137:17-25.
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.
THis study was done to determine the prevalence of osteonecrosis of the hip
HIV-infected patients and to identify potential risk factors associated with
This study is s survey and comparison study conducted at the Clinical Center
of the U.S. National Institutes of Health.
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
Osteonecrosis of the hip was measured, as documented by magnetic resonance
imaging. Data from clinic records and a patient questionnaire administered
magnetic resonance imaging were used in an analysis of risk factors. A subset
patients was evaluated for hypercoagulable state.
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
The authors concluded that 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.
Problems of the Hip Bone in Patients with HIV Infection
What is the problem and what is known about it so far?
HIV is the virus that causes AIDS. Since the mid 1990s, several powerful
(combinations of antiretroviral drugs) have helped increase length of life in
with HIV infection. The focus of care for patients with HIV infection has
managing long-term complications and complex drug regimens and their side
Recently, doctors have noted that some patients with HIV infection have a
the bone in their hip, in which part of the bone dies (osteonecrosis of the
condition can become painful and disabling. In some instances, surgery for a
replacement is needed. Osteonecrosis of the hip doesn't occur very often in
normal immune systems. Its frequency in people with HIV infection is not
Why did the researchers do this particular study?
To see whether osteonecrosis of the hip occurs frequently in people with HIV
Who was studied?
339 adults with HIV infection and 118 adults without HIV infection. None of
participants had hip pain or hip symptoms.
How was the study done?
Patients with HIV infection who were enrolled in special studies at the
of Health (NIH) were invited to have a magnetic resonance imaging (MRI) scan
of the hip
bone. This is a scan that uses radio waves and a magnetic field to produce
pictures of the bone. The researchers also invited "normal volunteers"
infection or other conditions to have the scan. Radiologists who did not know
the scans were from a person with HIV infection interpreted the scan results.
What did the researchers find?
Fifteen (4.4%) of the adults with HIV infection had osteonecrosis of the hip
MRI scan. Osteonecrosis was more frequent among the HIV-infected persons who
used steroids, lipid-lowering drugs, or testosterone and among those who
bodybuilding exercises. None of the adults without HIV infection were found
What were the limitations of the study?
The adults in this study had no symptoms. We do not know whether the
that was detected by MRI scans would have eventually caused hip pain or other
problems. Also, we cannot tell whether the osteonecrosis was caused by
specific to HIV infection or by some of the drugs taken and intense
exercises performed by some of the study participants who had HIV infection.
What are the implications of the study?
Asymptomatic patients with HIV infection have an unexpectedly high occurrence
osteonecrosis of the hip detected by MRI scan. Although this study did not
patients with hip pain, osteonecrosis should probably be considered in
persons who begin to have pain and problems with their hips.