Introduction:

The developing world often lacks the resources to effectively treat the most serious injuries, potentially resulting in severe complications of orthopaedic trauma, including osteomyelitis following open fractures or surgical fracture treatment. Antibiotic cement beads are now a widely accepted method of delivering antibiotics locally to the infected area following trauma. This study is based in Cambodia, a low income country struggling to recover from a recent genocide.

Introduction

Infection following traumatic injury of the tibia is challenging, with surgical debridement and prolonged systemic antibiotic therapy well established. Local delivery via cement beads has shown improved outcome, but these often require further surgery to remove. Osteoset-T is a bone-graft substitute composed of calcium sulphate and 4%-Tobramycin, available in pellets that are packed easily into bone defects. Concerns remain regarding the sterile effluent produced as it resorbs, along with the risk of acute kidney injury following systemic absorption.

Introduction

HIV is known to affect many of the processes involved in fracture healing. Recent work has suggested that CD4 cells may act as suppressor in the regulation of fracture healing. There are no clinical studies looking at fracture healing in patients with open fractures in these patients.

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:

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;

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.

There are 33 million people worldwide currently infected with human immunodeficiency virus (HIV). This complex disease affects many of the processes involved in wound and fracture healing, and there is little evidence available to guide the management of open fractures in these patients. Fears of acute and delayed infection often inhibit the use of fixation, which may be the most effective way of achieving union.

This study compared fixation of open fractures in HIV-positive and -negative patients in South Africa, a country with very high rates of both HIV and high-energy trauma. A total of 133 patients (33 HIV-positive) with 135 open fractures fulfilled the inclusion criteria. This cohort is three times larger than in any similar previously published study.

The results suggest that HIV is not a contraindication to internal or external fixation of open fractures in this population, as HIV is not a significant risk factor for acute wound/implant infection. However, subgroup analysis of grade I open fractures in patients with advanced HIV and a low CD4 count (< 350) showed an increased risk of infection; we suggest that grade I open fractures in patients with advanced HIV should be treated by early debridement followed by fixation at an appropriate time.

Aim: Retrospective analysis of paediatric supracondylar fractures treated by various closed and open methods of management and study co-relation between type of treatment and outcome.

Method: Retrospective review of children with displaced supracodylar fractures of humerus consecutively treated between January 1999 and December 2003. We included all the patients (63 children) admitted to hospital and had closed or open surgical procedure. Medical records and radiographs were reviewed to identify type of management, pre or postoperative complications, including loss of fracture reduction, infection, loss of motion of elbow and the need for additional surgery. 13 cases were excluded as insufficient records available and patients have either moved from area or treated on injury on holidays.

Results: In this study 70% of children were less than 8 year old. Except for one all the patients had extension type of injury and 58% of total cases had Gartland type III fracture configuration. 38% of patients were treated with closed reduction and immobilisation, 24% had closed reduction and percutaneus k-wires fixation and remaining had open reduction and internal fixation. All the patients underwent procedure with in 12 hrs of admission to hospital. Six patients had pre-operative neuro-vascular compromise and all of these patients recovered completely post-operatively. Loss of position was noted in 20% of children who had only manipulation and required re-manipulation and stabilisation with percutaneus k-wire fixation. All percutaneus fixations were with two lateral entry pin fixation and Open reduction were fixed with cross pin fixation. There was no clinically evident hyperextension or loss of motion but one patient (Gartland type III) who was treated with MUA and immobilisation required corrective osteotomy for cubitus varus. One patient had pin track infection but there was no iatrogenic nerve palsy.

Conclusion: Lateral entry pin fixation is very safe mode of fixation for percutaneus treatment and gives excellent results. Treatment with Manipulation and immobilisation for Gartland type III fractures does not give satisfactory results. We suspect early treatment of these fractures reduces comorbidity and early complications.

We present the results of the management of 17 relapsed club feet in 12 children using the Ilizarov method with gradual distraction and realignment of the joint. Review at a mean of three years after surgery showed maintenance of correction with excellent or good results in 13 feet. Five mobile feet which had been treated by a split transfer of the tibialis anterior tendon two weeks after removal of the frame had an excellent result.