Aim. 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. Method. 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. Results. 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). Conclusions. 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

Background:. There are multiple risk factors regarding the outcome of open tibia fractures treated with surgical fixation. In this study we have looked at delay to debridement and HIV infection as risk factors in the outcome of open tibia fractures. Methods:. We present a prospective study of 89 patients with open tibia fractures treated with surgical fixation with a significant delay to first debridement and a high prevalence of HIV infection. Primary outcome of this study was time to union and wound infection in the first 3 months. All patients admitted in our hospital between February 2011 and October 2012 with open fractures of the tibia requiring surgical fixation were included in the study. Patients were tested for HIV infection and multiple clinical parameters were documented, including; Gustilo-Anderson classification, ASEPSIS wound score, New Injury Severity Score(NISS), comorbidities, time to 1st debridement, time to 1st dose of antibiotics, pin site score, level of contamination, level training of the surgeon, high energy injuries, time to union and socio-economic parameters. Patients were followed to union. Results:. Twenty-five (28%) of the 89 patients were HIV positive. Forty-six (52%) patients had a delay to debridement of more than 24 hours. Eight (9%) patients developed wound infection in the first 3 months. Seventeen (19%) patients had a delayed union of more than 6 months. This study was underpowered to show a relation between wound infection and the clinical parameters of our patients. A logistic regression analysis showed that grade 3 Gustilo-Anderson injuries were associated with delayed union. We did not find an association between delayed union and; – HIV status, NISS, time to 1st debridement, high energy injuries, level of contamination and time to 1st dose of antibiotics. Conclusion:. This study suggests that delay to 1st debridement and HIV status are not significant risk factors for wound infection and delayed union in patients with open tibia fractures. There was a significant association between Gustilo-Anderson grade 3 open fractures of the tibia and delayed union. We stress the importance of good clinical judgment in the surgical treatment of open tibia fractures in a setting with high rates of HIV infection and limited resources

Background:. There is limited evidence regarding HIV infection as a risk factor for delayed union and implants sepsis in patient with fractures treated with surgical fixation. Most studies have included patient with a variety of different fractures and hence very different risks regarding delayed union and implant sepsis. We have looked at a single fracture, closed femoral shaft fractures treated with intramedullary nailing, to see if HIV infection is a risk factor with for the development of delayed union and implant sepsis. We present a prospective study of 160 patients with closed femoral shaft fractures treated with intramedullary nailing. Primary outcomes were delayed union of more than 6 months and implant sepsis in the first 12 months. Methods:. From February 2011 until November 2012 all patient with closed femoral shaft fractures treated at our hospital were included in the study. Patients were tested for HIV infection and a number of clinical parameters were documented, including: AO fracture score, duration of surgery, level of training of surgeon, comorbidities, CD4 count, high energy injury and number of operations. Results:. Forty (25%) patients were HIV positive. Seven patients had CD4 counts below 350 cells/µL and 12 patients were on ARV's. Four (3%) patients developed implants sepsis and of these 1 (25%) was HIV positive. Two (1%) patients had a delayed union of more than 6 months and both these patients were HIV negative. Conclusion:. HIV is not a risk factor for delayed union and implant sepsis in the first 12 months after surgery. Intramedullary nailing is a safe and effective in the treatment of HIV positive patients with closed femur fractures

Purpose of study. Pin tract infection is a common complication with the use of circular external fixators. HIV infection itself is frequently quoted as a relative contra-indication for the use of circular external fixators for complex trauma and limb reconstruction in HIV seropositive individuals. Methods. Between July 2008 and December 2012, 286 patients were treated with circular external fixators at our tertiary level government hospital. A retrospective review was undertaken to compare the rate and severity of pin tract sepsis in HIV seropositive and seronegative patients. Results. Two-hundred and twenty-three patients met the inclusion and exclusion criteria. Pin tract sepsis was found in 51 patients overall (22.8%). The incidences of pin tract sepsis in the seropositive group, seronegative group, and the unknown group are 22.5%, 22.8% and 23.8% respectively, and the differences were not statistically significant. The severity of pin tract sepsis in the individual groups was also similar. Conclusion. Pin tract sepsis is a common complication with the use of circular external fixators. The incidence and severity of pin tract infection is not influenced by HIV infection, and should not in itself deter from the use of circular external fixators for complex trauma and limb reconstruction in HIV seropositive individuals. NO DISCLOSURES

The April 2023 Hip & Pelvis Roundup³⁶⁰ looks at: Do technical errors determine outcomes of operatively managed femoral neck fractures in younger adults?; Single-stage or two-stage revision for hip prosthetic joint infection (INFORM); Fixation better than revision in type B periprosthetic fractures of taper slip stems; Can you maximize femoral head size at the expense of liner thickness?; Plasma D-dimer for periprosthetic joint infection?; How important is in vivo oxidation?; Total hip arthroplasty for HIV patients with osteonecrosis.

Fractures of the ankle are common, and they mostly affect young adults. Wound complications are not uncommon following the fixation of these fractures. This study evaluated the impact of HIV on wound healing after plate osteosynthesis in patients with closed ankle fractures.

This is an observational retrospective study of patients operated on at a tertiary level hospital. We reviewed hospital records for patients above 18 years of age who presented with wound breakdown following ankle open reduction and internal fixation. The patients’ hospital records were retrieved to identify all the patients treated for closed ankle fractures and those who developed wound breakdown. Patients with Pilon fractures were excluded. The National Health Laboratory System (NHLS) database was accessed to retrieve the CD4 count, viral load, haematology study results, and biochemistry results of these patients at the time of surgery and subsequent follow-up. The x-rays were retrieved from the electronic picture archiving system (PACS) and were assessed for fracture union at a minimum of 3 months follow-up.

We reviewed the medical records of 172 patients with closed ankle fractures treated from 2018 to 2022. Thirty-one (18.0%) developed wound breakdown after surgery, and they were all tested for HIV. Most of the patients were male (58.0%), and the average age of the cohort was 43.7 years (range: 21 years to 84 years). Ten of these patients (32.2%) were confirmed HIV positive, with CD4 counts ranging from 155 to 781. Viral load levels were lower than detectable in 40% of these patients. All patients progressed to fracture union at a minimum of 3 months follow-up.

We observed no difference between HIV-positive and HIV-negative patients in terms of wound breakdown and bone healing post-plate osteosynthesis for closed ankle fractures.

Infection of human cartilage with HIV in vivo has not previously been reported. Specimens of articular cartilage taken at postmortem from ten patients who were HIV-positive were examined. Two had AIDS and eight were believed to have stage-2 disease.

The standard polymerase chain reaction (PCR) protocol was modified to allow semiquantitative analysis of the samples. Oligonucleotide primers labelled with ³²P gamma-ATP were used to detect a segment of HIV DNA and a control DNA gene segment (HLA genome) to estimate the ratio of infected cells. The ³²P-labelled PCR products were separated on acrylamide gels and visualised directly by autoradiography and computer densitometry.

Infection of human cartilage in vivo was demonstrated in nine of the ten samples in which the PCR analysis was positive. The other did not react sufficiently to produce detectable radiolabelled PCR product despite repeated DNA digestion and extraction. Cartilage infected with HIV could be a potential source of HIV when used in operations.

Highly active anti-retroviral therapy has transformed HIV into a chronic disease with a long-term asymptomatic phase. As a result, emphasis is shifting to other effects of the virus, aside from immunosuppression and mortality. We have reviewed the current evidence for an association between HIV infection and poor fracture healing. The increased prevalence of osteoporosis and fragility fractures in HIV patients is well recognised. The suggestion that this may be purely as a result of highly active anti-retroviral therapy has been largely rejected. Apart from directly impeding cellular function in bone remodelling, HIV infection is known to cause derangement in the levels of those cytokines involved in fracture healing (particularly tumour necrosis factor-α) and appears to impair the blood supply of bone. Many other factors complicate this issue, including a reduced body mass index, suboptimal nutrition, the effects of anti-retroviral drugs and the avoidance of operative intervention because of high rates of wound infection. However, there are sound molecular and biochemical hypotheses for a direct relationship between HIV infection and impaired fracture healing, and the rewards for further knowledge in this area are extensive in terms of optimised fracture management, reduced patient morbidity and educated resource allocation. Further investigation in this area is overdue

Abstract. Aim. End-stage arthropathy is a well-known complication of haemophilia, with recurrent haemarthroses leading to joint destruction, deformity, pain, and stiffness. In the knee, this is often treated with total knee arthroplasty (TKA), which can be more challenging in patients with haemophilia (PwH) and associated with poorer outcomes. We conducted a systematic literature review and meta-analysis to determine implant survivorship, functional outcomes and complication rates. Method. A systematic review was conducted using MEDLINE, EMBASE, and PubMed for studies reporting TKA outcomes with Kaplan-Meier survivorship in PwH (PROSPERO registered). Meta-analysis was performed for survivorship and outcomes, and the results were compared to outcomes from the National Joint Registry (NJR). Results. 19 studies, totalling 1187 TKAs (average age 39 years) were reviewed. In PwH, implant survivorship at 5, 10, and 15 years was 94%, 86%, and 76% respectively, whereas NJR reported survivorship for males <55 years was 94%, 90%, and 86%. Survivorship generally improved over the time period studied (1973–2017), but was inversely correlated with HIV infection (common in PwH). Range of motion improved by 10–20° post-operatively, and there were large improvements in Patient Reported Outcome Measures (PROMS). The prosthetic joint infection rate (PJI) was 6% compared to 0.5-1% in non-PwH, but the reporting of other complications, especially haematological, was inconsistent. Conclusions. TKA in PwH has similar 5-year survivorship to non-PwH, but a six-fold higher infection rate. There were marked improvements in range of motion and PROMS, but complications were poorly reported. There remains a need for larger, long-term studies with standardised reporting

The prevalence of HIV infection in East Africa has increased rapidly in recent years. We made a prospective study of the incidence of HIV-seropositivity in patients undergoing orthopaedic procedures in a large district hospital in Bulawayo, Zimbabwe. One of our aims was to determine whether a clinically-based screening programme, derived from the Centre for Disease Control classification of HIV infection, could identify high-risk individuals before surgery. During a 3-month period, 76 patients were tested, and 12 were HIV-positive (16%). Only two of these patients (17%) had clinical features associated with HIV infection; ten (83%) were entirely asymptomatic. Our results indicate that preoperative clinical screening is unlikely to be successful in identifying seropositive patients before routine surgery

Aim. Periprosthetic joint infection (PJI) is a major complication of prosthetic implantation and needs a combined surgical and antimicrobial treatment. One-stage revision results usually in similar cure rate than two-stage (around 85–92%), but antibiotic therapy duration is not well established. The aim of study was to evaluate the efficacy of a short six-weeks antibiotic course in hip and knee PJIs after one-stage replacement arthroplasty (RA). Method. This was a retrospective, observational study conducted at Orthopaedic Department of Cochin Hospital, Paris, between 1stJanuary 2010 and 31 December 2015. Inclusion criteria were: age>18 years; clinical/microbiological diagnosis of PJI; one-stage RA; 6-weeks course of antibiotics; follow-up of at least one year. PJIs were classified depending on the delay of infection from implantation as: early(<3 months), delayed(3–24 months), late(>24 months). Pearson's-χ2 and t-tests were used to compare categorical and continuous variables. Results. Fifty patients with PJIs treated with one-stage hip/knee replacement arthroplasty (HRA/KRA) were included, 42 HRA, 8KRA. Median age was 69.3 years (IQR 24.5–97.4), 31 were males. Comorbidities included tumours(18%), polyarthritis(12%), chronic kidney disease (CKD), HIV infection. ASA score was ≥3 in 15(30%) cases. PJIs occurred after a mean of 36 months:9 early, 9 delayed, 32 late. Bone biopsy and synovial fluid cultures were positive for methicillin-susceptible coagulase-negative Staphylococci (MSCNS) in 19(65%) cases, methicillin-resistant CNS (MRCNS) in 5(17%), methicillin-susceptible S. aureus (MSSA) in 5(17%), P. acnes in 20(40%), Enterobacteriacae in 6(12%), Streptococcus spp. in 4(8%), E. faecium and Listeria spp.(2%). Twelve PJIs (24%) were polymicrobial. Intravenous antibiotics were administered for 11 days (IQR 4–45). Daptomycin was used in 22(44%) cases. Forty-six 46(92%) patients were switched to oral antibiotics: fluoroquinolones in 25(54%) cases, clindamycin in 19(41%), beta-lactams in 17(37%), rifampicin in 12(26%). One patient died due to a carcinoma, while others reached at least one year evaluation (IQR 12–60). Overall, the remission rate was 90%(HRA=90%, KRA=88%). Failures included 4 relapses and one reinfection: HRA in 80%, ASA score ≥3 in 40%. Infections recurred after 6 months (IQR 4–12); bacteria involved were: MSCNS(n=2), MSSA, P. acnes and ESBL-producing K. pneumoniae. Univariate analysis, performed for demographical and PJI parameters, showed no differences between success and failures, except for radiotherapy, HIV infection and CKD associated to worst prognosis (p=0.05, OR=10.7; remission rate=50%). The lowest rate of failures was observed with rifampicin use, but it was not significant(p=0.14). Conclusions. six-weeks course of antibiotics in knee and hip PJIs treated with one stage revision, seems sufficient with a satisfactory remission rate

Introduction. Pulmonary Tuberculosis (TB) can be detected by sputum cultures. However, Extra Pulmonary Spinal Tuberculosis (EPSTB), diagnosis is challenging as it relies on retrieving a sample. It is usually discovered in the late stages of presentation due to its slow onset and vague early presentation. Difficulty in detecting Mycobacterium Tuberculosis bacteria from specimens is well documented and therefore often leads to culture negative results. Diagnostic imaging is helpful to initiate empirical therapy, but growing incidence of multidrug resistant TB adds further challenges. Methods. A retrospective analysis of cases from the Infectious Disease (ID) database with Extra Pulmonary Tuberculosis (EPTB) between 1. st. of January 2015 to 31. st. of January. Two groups were compared 1) Culture Negative TB (CNTB) and 2) Culture Positive TB (CPTB). Audit number was. Results. 31 cases were identified with EPSTB. 68% (n=21) were male. 55% (n=17) patients were Asian, (19% (n=6) were black and 16% (n=5) were of white ethnicity. 90.4% (n=28) patients presented with isolated spinal TB symptoms. No patient had evidence of HBV/HCV/HIV infections. CPTB Group was 51.6% (n=16) compared to CNTB Group with 48.4% (n=15) 48% (15) lumbar involvement, 42% (13) thoracic and 10% (3) cervical. 38.7% (12) patients presented with late neurology, equally in both groups. 56% CPTB patients showed signs of vertebral involvement on plain radiograph compared to 13.3% in CNTB patients. 68.7% CPTB patients had pathological changes or paraspinal collections seen on CT scan compared to 53.3% of CNTB patients. 81% of CPTB showed positive MRI findings compared to 86% in CNTB. Both groups were treated with Anti-TB medications according to local guidelines. 83% patients were followed up till the end of the treatment course. 22.5% (n=7) patients had Ultrasound guided aspiration. 29% (n=9) patients underwent surgical intervention. 3 patients had Laminectomy for decompression. 6 patients underwent Spinal Decompression and Fixation due to extensive bone destruction. No mortality occurred. Conclusion. TB continues to be a growing problem in the developed world with high numbers of patients travelling from endemic regions. 75% of our cases were from Asian or Black ethnicity. The thoracolumbar region was most commonly effected (90%). Approximately 50% of cases of extrapulmonary spinal TB were culture negative. Neurological deficit occurred in 40% patients and 30% of patients required surgery. Standard anti-TB treatment was however effective in all cases with no significant drug resistant variants noted. MRI and CT imaging remain the superior diagnostic tests in the presence of high CN EPSTB

We present a case of Mycobacterium avium-intracellulare (MAI) infection of the ankle joint in a patient with HIV infection. The patient presented with a painful, destructive arthropathy of the ankle. Initial microbiological studies were negative but infection with MAI was later identified from biopsies taken during hindfoot fusion. Antibiotic triple therapy was given and the patient remains pain-free without evidence of active infection. To our knowledge, this is the first case of MAI infection of the ankle reported in the literature. A high index of suspicion of (atypical) Mycobacterial infection should be maintained in patients with HIV infection presenting with an indolent but destructive arthropathy of the ankle joint

Despite numerous advances in the management of chronic osteomyelitis, many questions remain. To date, no evidence-based guidelines exist in the treatment of chronic osteomyelitis. In essence the aim is to improve quality of life through either a curative or a palliative treatment strategy. The choice of treatment strategy is based on the physiological status of the host. This process of host stratification is, however, complicated by the fact that the definition of a C-host has never been standardized. Purpose;. The aim of the study was to investigate the short term outcome of the treatment of chronic osteomyelitis in adult patients where selection of a management strategy was based on a refined host stratification system. Methods;. A retrospective review was performed of adult patients with chronic osteomyelitis seen over a one year period. In total 116 patients were included in the study. A modified host stratification system was applied, incorporating predefined major and minor criteria, to determine each patient's host status. Results;. A high prevalence of HIV infection (28.6%) and malnutrition (15%) was present in the study population. Almost half the patients were classified as C-hosts (44.8% or n=52), followed by B-host classification in 39.7% of cases (n=46). At a mean follow-up of one year an overall success rate of 91.4% (95% CI: 84.7–95.8%) was achieved. Host status and outcome (remission, suppression or failure) was significantly dependent (p-value < 0.001). Success was achieved in 92.2% of patients treated curatively and 89.6% of patients treated palliatively. Conclusion;. By integrating the physiological status of the host (based on objective predefined criteria) with the appropriate curative, palliative or alternative treatment strategy we were able to achieve acceptable outcomes in both low and high risk cases and, in addition, avoid unnecessary amputation

Septic arthritis has been regarded as rare in haemophiliacs, but its incidence may have increased since HIV infection has become widespread in these patients. We describe six cases treated at one haemophilia unit over a two-year period and discuss their investigation, diagnosis and treatment. Four of the patients were seropositive to anti-HIV

Purpose of study:. To analyse the bacteriological spectrum, identify most appropriate antibiotics for hand infections, and to characterize patterns and sites of hand infections. This information was collected against the background of a high prevalence of HIV infected patients and increasing antibiotic resistance. Description of methods:. This was a prospective, cross-sectional, analytical study done on 66 patients presenting with hand infections at a public hospital from January to June 2009. A standardised treatment protocol was followed in managing these patients. Data was collected from each participant, and laboratory reports were followed up for the identity and antibiotic susceptibility of causative organisms. All patients were counselled for HIV status and consenting participants were tested. Summary of results:. Staphylococcus aureus was the commonest isolate. Results show that Cloxacillin is still an effective first line antibiotic for community acquired hand infections in the absence of immunosuppression. Alternative empiric therapy would be Clindamycin – especially in the B-lactamase intolerant patient. HIV infection played a significant role in the bacteriology of hand infections with an increased incidence of polymicrobial and gram negative infections. Data regarding age, gender, types of infection, mechanism of injury, x-ray findings and laboratory values are also reported. Conclusion:. Hand infections are common conditions that have significant morbidity. Referral is often delayed and infections present late. Immunosuppression seems to play a role in the bacteriology, the incidence of polymicrobial infections and the antibiotic sensitivity. Cloxacillin seems to be an adequate first line treatment for acute community acquired bacterial hand infections in immunocompetent patients in our institution, excluding human bites and farm yard injuries

Introduction. The resurgence of TB worldwide has several underlying causes, but HIV infection has undoubtedly been a key factor in the current TB epidemic. Since TB is endemic in the developing world the influence of HIV is of concern, particularly with the emergence of multi-drug-resistant strains. The remarkable susceptibility of patients with AIDS to develop TB has shown the critical role of CD4 lymphocytes in protective immunity. In the absence of immunological surveillance by CD4 cells, 5-10% of persons with latent foci of TB reactivate each year. Aim. This paper highlights the presentation and outcome following treatment in HIV patients with spinal TB. Methods. 81 HIV+ve patients with spinal tuberculosis were prospectively evaluated between 2006 and 2007. The mean age was 31 years and 63% were females. The thoracic spine was affected in 45, lumbar (33) and cervical (3). Non-contiguous lesions were noted in six patients. Sixty-six (81%) patients had neurological deficit. The mean Hb was (10.1gm/dl), mean WCC 4.9, mean lymphocyte count was 1.8, mean ESR 79mm/h and the mean CD4 count was 268 cell/cumm. Co-morbidities were seen in 68% of patients. All patients were optimised prior to treatment. Posterolateral decompression was performed in 29 cases, anterior decompression (25), needle biopsy (13), incision and drainage 5 and 9 were treated non-operatively. Medication included ARV (72 patients) and anti-TB in all patients. Results. The mean follow-up was 21 months. Eleven (13.5%) patients developed wound infection and one child died. Complete recovery occurred in 23 patients (35%). The mean CD4 count was 341 cell/cumm. Conclusion. The short term results are encouraging. These patients are best managed by a multidisciplinary team to monitor potential complications from dual therapy, to ensure compliance and adequate nutrition

Joint replacement in HIV-positive patients remains uncommon, with most experience gained in patients with haemophilia. We analysed retrospectively the outcome of 102 replacement arthroplasties in 73 HIV-positive patients from eight specialist haemophilia centres. Of these, 91 were primary procedures. The mean age of the patients at surgery was 39 years, and the median follow-up was for five years. The overall rate of deep sepsis was 18.7% for primary procedures and 36.3% for revisions. This is a much higher rate of infection than that seen in normal populations. A total of 44% of infections resolved fully after medical and/or surgical treatment. The benefits of arthroplasty in haemophilic patients are well established but the rates of complications are high. As this large study has demonstrated, high rates of infection occur, but survivorship analysis strongly suggests that most patients already diagnosed with HIV infection at the time of surgery should derive many years of symptomatic relief after a successful joint replacement. Careful counselling and education of both patients and healthcare workers before operation are therefore essential