STUDY INTO OUTCOMES OF OPEN FRACTURES TREATED WITH INTERNAL FIXATION, IN RELATION TO HIV CO-INFECTION

Abstract

Background: The importance of HIV in trauma has been poorly investigated. There’re few reports in the literature on the effects of HIV on fracture healing, those that there are involve small numbers. Many surgeons have concerns about both internal and external fixation in these patients.

Some of the most recent published studies have suggested a 4 fold increase in infection rates in internal fixation of open fractures (small series 39 patients, 12 of whom HIV positive)

In our hospital we have prospectively reviewed the outcomes of our open fractures treated by internal fixation, to see if HIV is a significant risk factor for wound infection and non union.

Methods: All patients undergoing internal fixation for open fractures were entered into a database. Patients were managed along predesigned protocols, under the care of one consultant to try and standardise care. Patients were followed up in a dedicated clinic. 96% 2 month follow up and 84% 3 month follow up was obtained

Results: Over a 9 month period 102 open fractures were treated with internal fixation. 23% of patients were HIV positive and 14% declined to be tested. CD4 counts ranged from 131–862, mean of 387. The superficial wound infection rate was 13% in HIV positive patients and 15% in HIV negative patients. Sub group analysis suggested that HIV positive patients with low CD4 counts and grade 1 injuries were significantly more likely to develop wound infections (50%) than controls (12%), p value=0.02. Grade 1 injuries were not managed with urgent debridement, under hospital guidelines, and had an average delay to theatre of 4 days. Rates of non union were 4% and 2% in the HIV positive/negative groups respectively.

Conclusions: This series is the largest prospective study in the literature. Our data suggests that:

1. The risks of acute infection in open fractures fixed by internal fixation in HIV positive individuals may not be as high as some previous studies have suggested;

2. Open fractures in HIV positive patients can be managed to union with internal fixation;

3. That in may not be appropriate to leave grade 1 injuries in HIV positive patients for non urgent debridement/fixation, as previous studies have suggested.

Discussion: We feel that the current dogma of denying such patients internal fixation, is no longer appropriate. Although this study does not provide a direct comparison between differing Methods: of fixation, it provides the strongest evidence available in the literature, that internal fixation should be considered as a treatment option in these patients. We are currently awaiting the result of long term follow up looking at rates of delayed sepsis in these patients.