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.

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.

We compared early post-operative rates of wound infection in HIV-positive and -negative patients presenting with open tibial fractures managed with surgical fixation.

The wounds of 84 patients (85 fractures), 28 of whom were HIV positive and 56 were HIV negative, were assessed for signs of infection using the ASEPIS wound score. There were 19 women and 65 men with a mean age of 34.8 years. A total of 57 fractures (17 HIV-positive, 40 HIV-negative) treated with external fixation were also assessed using the Checkett score for pin-site infection. The remaining 28 fractures were treated with internal fixation. No significant difference in early post-operative wound infection between the two groups of patients was found (10.7% (n = 3) vs 19.6% (n = 11); relative risk (RR) 0.55 (95% confidence interval (CI) 0.17 to 1.8); p = 0.32). There was also no significant difference in pin-site infection rates (17.6% (n = 3) vs 12.5% (n = 5); RR 1.62 (95% CI 0.44 to 6.07); p = 0.47).

The study does not support the hypothesis that HIV significantly increases the rate of early wound or pin-site infection in open tibial fractures. We would therefore suggest that a patient’s HIV status should not alter the management of open tibial fractures in patients who have a CD4 count > 350 cells/μl.

Cite this article: Bone Joint J 2013;95-B:1703–7.

A high volume of trauma and limited resources means that traditional methods of bone reconstruction are not feasible in parts of Africa. We present the management and outcomes of using Masquelet's concept, of an induced membrane and secondary morcellised cancellous bone grafting, in patients with severe lower limb trauma.

Eleven patients were treated in an orthopaedic department in rural southern Africa between 2011 and 2012. This is a subgroup that is part of a larger study of open fractures that received ethical approval.

All patients were male, with ten aged between 20 and 35 and one aged 70. Two were HIV positive. There were three open femur and eight open tibia fractures. Three required fasciocutaneous flaps and one required a muscle flap to achieve adequate soft tissue coverage. Eight cases were performed as the primary treatment and three were to treat septic non-unions. Bone defects ranged from 4 to 10 cm. Definitive bony stabilisation was maintained by mono-lateral external fixator in three patients. In other cases this was converted to a circular frame or internal fixation.

The results have been mixed. In three patients bone grafting was delayed due to wound or pin site problems. In one case the bone graft was lost due to infection but repeating the procedure produced a good result. Time to bony union in each case is difficult to quantify. However, there is clear evidence of new bone forming in most cases. Four patients are weight bearing with external fixation removed, as are five patients with internal fixation. In a few cases bony union appears to be taking significantly longer, if at all.

Masquelet technique is a welcome addition to the options available in bone reconstruction. However, time to achieve bony union is unpredictable. Refinement of the technique for use in the developing world is needed.

Background

In 2011 Aird et al published their results of the effects of HIV on early wound healing in open fractures treated with internal and external fixation. The study was conducted between May 2008 and March 2009 and performed in semi-rural area of KwaZulu-Natal, South Africa. These results suggested that HIV is not a contraindication to internal or external fixation of open fractures, as HIV is not a significant risk factor for acute wound implant infection. We present a longer term follow up of this same cohort of patients from the original study.