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.

Methods.

We conducted a single centre prospective observational study comparing post-operative infection rates in HIV positive and HIV negative patients presenting with tibial shaft fractures managed with surgical fixation.

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.

Introduction

A recent retrospective study of distal femoral physeal fractures (DFPFs) suggested closed manipulation alone has a high incidence of re-displacement, malunion or physeal bar formation. The paper concluded that all displaced DFPFs require internal fixation, and breaching the physis with k-wires is safe. We agree that hyper-extension/flexion injuries need stabilisation using k-wires but, in our experience, purely valgus/varus deformities can be successfully managed by manipulation under anaesthesia (MUA) and a moulded cylinder cast.

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.

Background: Blount’s original paper in 1937 described a case series of 28 patients with “Tibia Vara”. Since then various authors have attempted to describe in more detail the tibial and femoral deformities seen in this disease. It is still a poorly understood condition. This study describes the femoral rotational deformity that can occur in Blount’s disease.

Methods: Over a 2 year period, all patients with Blount’s disease seen in the Orthopaedic department of a regional hospital in South Africa were entered into a database. They underwent a review of their notes, a clinical rotational profile of their lower limbs and a CT scan of the femoral head/neck and distal femur. From this database we performed a cross sectional study. We then compared our results both to previously published controls for hip rotation and anteversion angles and with respect to the rotational profile, to a small cohort of 32 “normal” local children.

Results: A statistically significant increase in femoral anteversion in the affected legs was noted, with on average the femurs in Blount’s disease being 26 degrees more anteverted than previously published controls. A significant decrease in external rotation were also noted.

Conclusions: Our results suggest that the marked intoeing seen in many cases of Blount’s disease may be caused by internal femoral version, in addition to the well recognized internal tibial version. This study highlights the following issues:

A rotational profile should be part of the routine clinical assessment of all Blount’s cases.

In 1937 Blount described a series of 28 patients with ‘Tibia vara’. Since then, a number of deformities in the tibia and the femur have been described in association with this condition.

We analysed 14 children with Blount’s disease who were entered into a cross-sectional study. Their mean age was 10 (2 to 18). They underwent a clinical assessment of the rotational profile of their legs and a CT assessment of the angle of anteversion of their hips (femoral version). We compared our results to previously published controls. A statistically significant increase in femoral anteversion was noted in the affected legs, with on average the femurs in patients with Blount’s disease being 26° more anteverted than those in previously published controls.

We believe this to be a previously unrecognised component of Blount’s disease, and that the marked intoeing seen in the disease may be partly caused by internal femoral version, in addition to the well-recognised internal tibial version.