To conduct a systematic review and meta-analysis comparing the development of early and late fracture-related infections (FRI) following closed and open fractures in HIV-positive and HIV-negative patients.
A systematic literature search was conducted using MEDLINE through the OVID interface, ProQuest, Web of Science, The Cochrane Library and Scopus. Only studies involving HIV-positive who underwent operative fixation (internal or external) of open or closed fractures, with a HIV-negative control group, were considered eligible. Following eligibility assessment, studies were included with the main outcome of interest being the development of either early or late fracture-related infection at the site of surgery in patients with open and closed fractures.
Eleven studies were included (n = 2634). The studies’ follow-up periods were between one and 39 months with an average of 11 months. Three studies were conducted before the introduction of ARV (anti-retroviral) therapy (1994) and two did not involve any patients on ARV's. Across the entire group, for both open and closed fractures, the risk of a fracture-related infection was greater in HIV-positive patients (Odds ratio (OR) = 1.61; 95% CI = 0.93–2.79, p = 0.04). When looking at closed fractures treated operatively, an OR = 4.59 was found in HIV-positive patients in terms of the risk of fracture-related infection (95% CI = 0.30–68.99, p < 0.001). Open fractures showed similar results with an OR of 3.48 in HIV-positive patients (95% CI = 0.55 – 21.99, p < 0.001). Studies performed prior to the widespread introduction of anti-retroviral therapy and/or did not have any patients on antiretroviral therapy showed a greater infection risk in patients living with HIV infection with OR 3.53 (95% CI = 1.85 – 6.74, p = 0.36). However, studies performed in the era after the introduction of antiretroviral therapy showed no increase of infection risk for HIV-positive patients with an OR = 0.91 (95% CI = 0.58 – 1.43, p = 0.76).
The assumption that HIV infection increases the risk for fracture-related infection remains unsubstantiated. The introduction of anti-retroviral therapy may have confounded the issue and we noted an apparent decrease in the risk in later studies. More data is required from well-designed larger studies to inform future analysis.