Fracture management in HIV positive individuals: a systematic review. Int Orthop. 2016;40:2429-2445. [PMID: 27655034 DOI: 10.1007/s00264-016-3285-1]

A novel web-based risk calculator for predicting surgical site infection in HIV-positive facture patients: a multicenter cohort study in China

Background

Surgical site infection (SSI) is a common complication in HIV-positive fracture patients undergoing surgery, leading to increased morbidity, mortality, and healthcare costs. Accurate prediction of SSI risk can help guide clinical decision-making and improve patient outcomes. However, there is a lack of user-friendly, Web-based calculator for predicting SSI risk in this patient population.

Objective

This study aimed to develop and validate a novel web-based risk calculator for predicting SSI in HIV-positive fracture patients undergoing surgery in China.

Method

A multicenter retrospective cohort study was conducted using data from HIV-positive fracture patients who underwent surgery in three tertiary hospitals in China between May 2011 and September 2023. We used patients from Beijing Ditan Hospital as the training cohort and patients from Chengdu Public Health and Changsha First Hospital as the external validation cohort. Univariate, multivariate logistic regression analyses and SVM-RFE were performed to identify independent risk factors for SSIs. A web-based calculator was developed using the identified risk factors and validated using an external validation cohort. The performance of the nomogram was evaluated using the area under the receiver operating characteristic (AUC) curves, calibration plots, and decision curve analysis (DCA).

Results

A total of 338 HIV-positive patients were included in the study, with 216 patients in the training cohort and 122 patients in the validation cohort. The overall SSI incidence was 10.7%. The web-based risk calculator (https://sydtliubo.shinyapps.io/DynNom_for_SSI/) incorporated six risk factors: HBV/HCV co-infection, HIV RNA load, CD4+ T-cell count, Neu and Lym level. The nomogram demonstrated good discrimination, with an AUC of 0.890 in the training cohort and 0.853 in the validation cohort. The calibration plot showed good agreement between predicted and observed SSI probabilities. The DCA indicated that the nomogram had clinical utility across a wide range of threshold probabilities.

Conclusion

Our study developed and validated a novel web-based risk calculator for predicting SSI risk in HIV-positive fracture patients undergoing surgery in China. The nomogram demonstrated good discrimination, calibration, and clinical utility, and can serve as a valuable tool for risk stratification and clinical decision-making in this patient population. Future studies should focus on integrating this nomogram into hospital information systems for real-time risk assessment and management.

Fracture-related wound infections following surgical treatment of fractures in HIV-positive and HIV-negative patients: A meta-analysis

The meta-analysis aims to evaluate and compare fracture-associated wound infections (FAWIs) following surgical treatment of fractures in human immunodeficiency virus (HIV)-positive and HIV-negative patients. Examinations comparing HIV-negative to HIV-negative for fracture was among the meta-analysis from various languages that met the inclusion criteria. Using dichotomous random or fixed models, the results of these investigations were examined, and the Odds ratio (OR) with 95% confidence intervals was computed (CIs). 14 examinations from 1991 to 2023 were recruited for the current analysis including 3528 personals with fractures. HIV-positive had significantly higher FAWI before antiretroviral (OR, 3.59; 95% CI, 2.01-6.41, p < 0.001) compared to HIV-negative personals with fractures. However, no significant difference was found between HIV-positive and HIV-negative in FAWI after antiretroviral (OR, 0.58; 95% CI, 0.30-1.12, p = 0.10) in personals with fractures. The examined data revealed that HIV-positive had significantly higher FAWI before antiretroviral, however, no significant difference was found in FAWI after antiretroviral compared to HIV-negative personals with fractures. Nevertheless, caution should be exercised while interacting with its values since some of the chosen examinations were found with a low sample size and a low number of examinations were found for the comparisons studied for the meta-analysis.

Is human immunodeficiency virus a risk factor for the development of nonunion?-a case-control study

Objective

Human immunodeficiency virus (HIV) infection has been suggested to be associated with an increased risk of the development of nonunion after a fracture. This prospective matched case-control study in South Africa investigated common risk factors, including HIV status, that influence the development of a nonunion after a femur or tibia fracture.

Methods

Adult participants (cases) with established nonunions of the femur or tibia shaft were recruited over a 16-month period, between December 2017 and April 2019. They were matched for (1) age; (2) sex; (3) fracture site; and (4) fracture management type, with "control" participants who progressed to fracture union within 6 months of injury. All participants were tested for HIV. Multivariable logistic regression models were constructed to investigate associations between known risk factors for the development of nonunion and impaired fracture healing.

Results

A total of 57 cases were matched with 57 "control" participants (44/57 male, 77.2% vs. 13/57 female, 22.8%, median age 36 years). HIV status was not associated with the development of nonunion after the management of tibia and femur fractures, on both univariate (odds ratio, 0.40; confidence interval, 0.10-1.32; P = 0.151) or multivariable (odds ratio, 0.86; confidence interval, 0.18-3.73; P = 0.831) analysis. No other confounding factors were shown to have any statistically significant impact on the odds of developing nonunion in this study cohort.

Conclusion

This study demonstrates that HIV does not seem to increase the risk of the development of nonunion and HIV-positive individuals who sustain a fracture can be managed in the same manner as those who are HIV negative.

Efficacy of single-stage posterior surgery for HIV-positive patients with thoracolumbar tuberculosis

OBJECTIVE

We aimed to observe the clinical effect of single-stage posterior surgery on HIV-positive patients with thoracolumbar tuberculosis.

METHODS

From October 2015 to October 2019, 13 HIV-positive patients with thoracolumbar tuberculosis who underwent single-stage posterior surgery were retrospectively analyzed (observation group), and 13 HIV-negative patients with thoracolumbar tuberculosis who were matched with the gender, age, operative site, and surgical approach during the same period were selected as the control group. Postoperative complications, hemoglobin, albumin, CD4⁺T lymphocyte count, operative site, operative time, and blood loss were recorded between the two groups. The clinical efficacy was evaluated by the visual analog scale (VAS), American Spinal Injury Association (ASIA) scale, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), kyphotic angle, correction rate of kyphosis, angle loss, and bone graft fusion time.

RESULTS

In the observation group, 7 patients had postoperative complications, including 1 patient with cerebrospinal fluid leakage, 1 patient with nerve root irritation, 1 patient with an opportunistic infection, and 4 with delayed wound healing. In the control group, 2 patients developed postoperative complications, including 1 with nerve root irritation and 1 with delayed wound healing. There was no statistically significant difference in the incidence of postoperative complications between the two groups (P > 0.05). CD4⁺T lymphocyte count, hemoglobin, and albumin in HIV-positive patients with postoperative complications were statistically different from those without postoperative complications (P all < 0.05). No tuberculosis recurrence was found at the last follow-up, ESR and CRP returned to normal, and there were no statistically significant differences in bone graft fusion time, VAS score, ASIA scale, correction rate of kyphosis, and angle loss between two groups (P all > 0.05).

CONCLUSION

Single-stage posterior surgery for HIV-positive patients with thoracolumbar tuberculosis could achieve satisfactory clinical efficacy through comprehensive preoperative evaluation, standardized perioperative antiviral and anti-tuberculosis treatments, and prevention of postoperative complications.

The effect of anti-retroviral therapy on fracture healing : an in vivo animal model

AIMS

A number of anti-retroviral therapies (ART) have been implicated in potentially contributing to HIV-associated bone disease. The aim of this study was to evaluate the effect of combination ART on the fracture healing process.

METHODS

A total of 16 adult male Wistar rats were randomly divided into two groups (n = eight each): Group 1 was given a combination of Tenfovir 30 mg, Lamivudine 30 mg, and Efavirenz 60 mg per day orally, whereas Group 2 was used as a control. After one week of medication preload, all rats underwent a standardized surgical procedure of mid-shaft tibial osteotomy fixed by intramedullary nail with no gap at the fracture site. Progress in fracture healing was monitored regularly for eight weeks. Further evaluations were carried out after euthanasia by micro-CT, mechanically and histologically. Two blinded orthopaedic surgeons used the Radiological Union Scoring system for the Tibia (RUST) to determine fracture healing.

RESULTS

The fracture healing process was different between the two groups at week 4 after surgery; only two out of eight rats showed full healing in Group 1 (ART-treated), while seven out of eight rats had bone union in Group 2 (control) (p = 0.040). However, at week eight postoperatively, there was no statistical difference in bone healing; seven out of eight progressed to full union in both groups.

CONCLUSION

This study demonstrated that combination ART resulted in delayed fracture healing at week 4 after surgery in rats, but did not result in the development of nonunion.Cite this article: Bone Joint Res 2022;11(8):585-593.

Complications and surgical treatment after pathological fracture associated to HIV secondary disease. A case report

Due to advances in retroviral treatment, human immunodeficiency virus (HIV)-related disease may become chronic and the patient survival has substantially increased. Osteoarticular disease in those patients include multifocal osteonecrosis and its complications. Pain and functional limitation may be due to these complications, frequently underdiagnosed, including pathological fractures. Its prompt management may require a different approach than osteosynthesis. We present a long-term chronic HIV patient with severe pain and limitation. A tibial plateau pathological fracture associated to multifocal osteonecrosis was identified and treated with osteonecrosis debridement and total knee arthroplasty (TKA). Acute periprosthetic joint infection developed and required debridement, antibiotic and implant retention. The contralateral knee, also with multiple osteonecrosis foci, was managed with early TKA. We highlight the importance of timely surgical reconstruction to avoid serious limitation and complications.

Fracture Healing in Patients With HIV in South Africa: A Prospective Cohort Study

BACKGROUND

HIV reduces bone mineral density, mineralization, and turnover and may impair fracture healing.

SETTING

This prospective cohort study in South Africa investigated whether HIV infection was associated with impaired fracture healing after trauma.

METHODS

All adults with acute tibia and femur fractures who underwent intermedullary (IM) nailing for fracture fixation between September 2017 and December 2018, at 2 tertiary hospitals, were followed up for a minimum of 12 months postoperatively. The primary outcome was delayed bone union at 6 months (defined by the radiological union scoring system for the tibia score <9), and the secondary outcome was nonunion (defined as radiological union scoring system for the tibia score <9) at 9 months. Multivariable logistic regression models were constructed to investigate the associations between HIV status and impaired fracture healing.

RESULTS

In total, 358 participants, who underwent 395 IM nailings, were enrolled in the study and followed up for 12 months. Seventy-one of the 358 (19.8%) participants were HIV-positive [83/395 (21%) IM nailings]. HIV was not associated with delayed fracture healing after IM nailing of the tibia or femur (multivariable odds ratio: 1.06; 95% confidence interval: 0.50 to 2.22). HIV-positive participants had a statistically significant lower odds ratio of nonunion compared with HIV-negative participants (multivariable odds ratio: 0.17; 95% confidence interval: 0.01 to 0.92).

CONCLUSIONS

Fractures sustained in HIV-positive individuals can undergo surgical fixation as effectively as those in HIV-negative individuals, with no increased risk of delayed union or nonunion.

What Are the Risk Factors for Surgical Site Infection in HIV-Positive Patients Receiving Open Reduction and Internal Fixation of Traumatic Limb Fractures? A Retrospective Cohort Study

A lack of studies analyze risk factors associated with surgical site infection (SSI) in human immunodeficiency virus (HIV)-positive patients with trauma undergoing orthopedic surgery. We questioned, (1) "What is the proportion of SSI in HIV-positive patients receiving open reduction and internal fixation (ORIF) of traumatic limb fractures?" and (2) "What are the independent risk factors for SSI of HIV-positive patients with traumatic limb fractures who received ORIF?" A retrospective study was performed in our institution from May 2011 to December 2019. A total of 246 patients were enrolled. Data of HIV-positive adult patients with traumatic limb fractures treated by ORIF were extracted from the electronic medical records, including the demographic information, characteristics of fractures, treatment-related variables, and indexes of laboratory examination. Multivariable logistic regression was used to identify independent predictors of SSI. A total of 26 patients developed SSI in this study, the overall proportion was 10.6% [95% confidence interval (CI) = 7.2%-15.3%]. Among them, 18 cases (7.3%) suffered from superficial SSI and 8 cases (3.3%) had the deep SSI. Independent predictors of SSI identified by multivariable logistic regression analysis were CD4⁺ T-lymphocyte count (adjusted odds ratio per 100/μL increase = 0.55; 95% CI = 0.37-0.81; p = .002) and albumin (adjusted odds ratio per 5 g/liter increase = 0.50; 95% CI = 0.30-0.81; p = .003). We recommend that orthopedic surgeons assess immunosuppression and nutritional status of HIV-positive patients rigorously and optimize the perioperative strategy of supplementary to reduce the risk of SSI.

The Early Results of Vertebral Pathological Compression Fracture of Extra- nodal Lymphoma with HIV-positive Patients Treated by Percutaneous Kyphoplasty

BACKGROUND

Vertebral pathological compression fracture involving extra-nodal lymphoma impacts negatively on the quality of life of HIV-positive patients. The choice of a safe and effective approach to palliative care in this condition remains a challenge.

OBJECTIVE

The purpose of this study was to investigate the safety and efficacy of percutaneous kyphoplasty (PKP) in the treatment of vertebral pathological compression fracture of extra-nodal lymphoma in HIV-positive patients.

METHODS

A retrospective analysis, from January 2016 to August 2019, was performed on 7 HIVpositive patients, 3 males and 4 females, with extra-nodal lymphoma with a vertebral pathological compression fracture. The patients were treated using percutaneous kyphoplasty in our hospital. Preoperative assessment of the patients was conducted regarding their hematological profile, biochemical indicators, liver and kidney function, blood coagulation function, CD4+T lymphocyte count and viral load. Subsequently, the patients were placed on highly active antiretroviral therapy (HAART) and rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP) regimen. Besides, antibiotics, nutritional support and immune-modulating drugs were also administered, rationally. Postoperatively, the height of the anterior edge of the injured vertebrae, Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) values were evaluated. Patients were also monitored for any complications related to the operation.

RESULTS

The average CD4+T cell count for the patients was 164 (range 114 ~247 / ul), while the viral load was 26,269 (range 5,765 ~82,321 copies/ul). All patients received nutritional and immune support and registered significant improvements in the levels of ALB and Hb (P<0.05). In all cases, the operation was uneventful with neither cement leakage nor toxic reactions observed. Similarly, no opportunistic infections, other complications or deaths were reported. The height of the anterior vertebral body and the ODI score of the injured vertebrae were significantly improved immediately after surgery (P<0.05). Compared to the preoperative VAS (7.71±1.11), postoperative values were significantly reduced immediately after surgery (3.85±0.90) and at 2 weeks, 1 month and 6 months post-surgery: 2.71±0.76, 3.29±1.11, and 4.00±0.82, respectively (P<0.01).

CONCLUSION

Supported with appropriate perioperative treatment measures, PKP is safe and effective in the treatment of pathological vertebral compression fracture due to extra-nodal lymphoma in HIV-positive patients.

Bibliometric analysis of research on the effects of human immunodeficiency virus in orthopaedic and trauma surgery

BACKGROUND

There is little research investigating how human immunodeficiency virus (HIV) affects outcomes in orthopaedic surgery. With advances in treatment, HIV has become a chronic health problem and the chance of orthopaedic surgeons encountering it in clinical practice is increasing.

AIM

To ascertain the quantity and quality of peer-reviewed publications in orthopaedic journals about HIV.

METHODS

A search of the Web of Science database was carried out, identifying any articles relating to HIV published in orthopaedic journals. These were assessed for geographic origin and level of evidence.

RESULTS

Of 48.7% of orthopaedic journals listed on the Web of Science database had published articles relating to HIV. There were 168 articles about HIV in orthopaedic journals with only 40.5% (n = 68) published in the time frame we analysed (January 2007 to September 2017). Very few articles came from low-income countries and any articles published from that setting were collaborations. All of the articles were low level of evidence.

CONCLUSION

There is a need for more high level orthopaedic and trauma research investigating the effects of HIV, particularly research from low-income countries, where higher level research will help to guide improvements in their treatment of its musculoskeletal manifestations and complications.

Delays to Surgery and Coronal Malalignment Are Associated with Reoperation after Open Tibia Fractures in Tanzania

BACKGROUND

Treatment of diaphyseal open tibia fractures often results in reoperation and impaired quality of life. Few studies, particularly in resource-limited settings, have described factors associated with outcomes after these fractures.

QUESTIONS/PURPOSES

(1) Which patient demographic, perioperative, and treatment characteristics are associated with an increased risk of reoperation after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania? (2) Which patient demographic, perioperative, and treatment characteristics are associated with worse 1-year quality of life after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania?

METHODS

A prospective study was completed in parallel to a similarly conducted RCT at a tertiary referral center in Tanzania that enrolled adult patients with diaphyseal open tibia fractures from December 2015 to March 2017. Patients were treated with either a statically locked intramedullary nail or external fixator and examined at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively. The primary outcome, reoperation, was any deep infection or nonunion treated with a secondary intervention. The secondary outcome was the 1-year EuroQol-5D (EQ-5D) index score. There were 394 patients screened and ultimately, 267 patients enrolled in the study (240 from the primary RCT and 27 followed for the purposes of this study). Of these, 90% (240 of 267) completed 1-year follow-up and were included in the final analysis. This group comprised 110 patients who underwent IMN and 130 who had external fixation; follow-up was similar between study groups. Patients were an average of 33 years old and were primarily males who sustained road traffic injuries resulting in AO/Orthopaedic Trauma Association (OTA) classification type A or B fractures. There were 51 reoperations. For the purposes of analysis, all patients were pooled to identify all other factors, in addition to treatment type, associated with increased risk of reoperation and 1-year quality of life. An exploratory bivariable analysis identifying various factors associated with reoperation risk and EQ-5D was subsequently included in a multivariate modeling procedure to control for confounding of effect on our primary outcome. Multivariable modeling was performed using standard hierarchical modeling simplification procedures with log-likelihood ratios. Alpha levels were set to 0.05.

RESULTS

After controlling for potentially confounding variables such as gender, smoking status, mechanism of injury, and treatment type, the following factors were independently associated with reoperation: Time from hospital presentation to surgery more than 24 hours (odds ratio 7.7 [95% confidence interval 2.1 to 27.8; p = 0.002), AO/OTA fracture classification Type 42C fracture (OR 4.2 [95% CI 1.2 to 14.0]; p = 0.02), OTA-Open Fracture Classification muscle loss (OR 7.5 [95% CI 1.3 to 42.2]; p = 0.02), and varus coronal angle on an immediate postoperative AP radiograph (OR 4.8 [95% CI 1.2 to 14.0]; p = 0.002). After again controlling for confounding variables such as gender, smoking status, mechanism of injury, and treatment type factors independently associated with worse 1-year EQ-5D scores included: Wound length ≥ 10 cm (ß = [change in EQ-5D score] -0.081 [95% CI -0.139 to -0.023]; p = 0.006), OTA-Open Fracture Classification muscle loss (ß = -0.133 [95% CI -0.215 to -0.051]; p = 0.002), and OTA-Open Fracture Classification bone loss (ß = -0.111 [95% CI -0.208 to -0.013]; p = 0.03). We observed a modest, but independent association between reoperation and worse 1-year EQ-5D scores (ß = -0.113 [95% CI -0.150 to -0.077]; p < 0.001).

CONCLUSIONS

We found two potentially modifiable factors associated with the risk of reoperation: reducing time to surgical treatment and avoiding varus coronal angulation during definitive stabilization. Hospitals may be able to minimize time to surgery, and thus, reoperation, by increasing the number of available operative personnel and space and emphasizing the importance of open tibia fractures as an injury requiring emergent orthopaedic management. Given the lack of fluoroscopy in the study setting and similar settings, surgeons should emphasize appropriate fracture alignment, even into slight valgus, to avoid varus angulation and subsequent reoperation risk.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Fracture-related infections in HIV infected patients: A systematic review and meta-analysis

Aim

To conduct a systematic review and meta-analysis comparing the incidence of fracture-related infections (FRI) following surgical management of closed and open fractures in HIV-positive and HIV-negative patients.

Methods

A systematic literature search was conducted using MEDLINE, ProQuest, Web of Science, The Cochrane Library and Scopus. Our own files and reference lists of identified key articles were also searched. We included studies where the primary outcome was the development of FRI in patients with open and closed fractures.

Results

Eleven studies were included for data synthesis. HIV-positive patients had a non-significant increase in FRI when compared to HIV-negative patients (in open and closed fractures combined). Open fractures treated in the pre-antiretroviral era had a 5.6 times greater risk for developing a FRI. In the post-antiretroviral era (1997 onwards) HIV-positive patients did not have a greater risk of FRI than HIV-negative patients for both open and closed fractures. The small retrospective natures of these studies, together with the heterogeneous outcome definitions used, are limitations to this study.

Conclusion

While there are few large prospective studies, the available data suggests that before the introduction antiretroviral therapy HIV infection was associated with a greater risk of FRI. In the post-antiretroviral era HIV infected patients did not show an increased risk of FRI.

Analysis of the surgical treatment of fracture in HIV positive patients: A clinical study

Objective:

To evaluate the incidence of postoperative infection and fracture nonunion as well as the risk factors for postoperative infection in human immunodeficiency virus (HIV) positive patients.

Methods:

From May 2013 to March 2016, the HIV positive fracture patients treated surgically in orthopaedics department of our hospital were analyzed retrospectively, and fifty HIV negative fracture patients during the same period were selected as control. The clinical data of included patients were reviewed. The incidence of postoperative infection and fracture nonunion were compared between the two groups, and the risk factors for postoperative infection in HIV positive patients were evaluated.

Results:

The incidence of poor wound healing and incision infection in HIV positive group was higher than that in HIV negative group, but there were no significant differences between the two groups (p>0.05). Multivariable regression analysis demonstrated that HIV clinical category (p<0.05), CD4+T-lymphocyte category (p<0.01) and open fracture (p<0.05) were independent risk factors for postoperative wound infections, but age, gender, operation time, incision type, emergency operation, albumin and lymphocyte count were not (p>0.05). There was no significant difference in the rate of nonunion between the two groups (p>0.05).

Conclusion:

The incision can be healed, and fracture can be united normally in most of HIV positive patients with fracture, and postoperative wound infections were significantly associated with HIV clinical category, CD4+T-lymphocyte category and open fracture.

Infected nonunion of tibia

Infected nonunions of tibia pose many challenges to the treating surgeon and the patient. Challenges include recalcitrant infection, complex deformities, sclerotic bone ends, large bone gaps, shortening, and joint stiffness. They are easy to diagnose and difficult to treat. The ASAMI classification helps decide treatment. The nonunion severity score proposed by Calori measures many parameters to give a prognosis. The infection severity score uses simple clinical signs to grade severity of infection. This determines number of surgeries and allows choice of hardware, either external or internal for definitive treatment. Co-morbid factors such as smoking, diabetes, nonsteroidal anti-inflammatory drug use, and hypovitaminosis D influence the choice and duration of treatment. Thorough debridement is the mainstay of treatment. Removal of all necrotic bone and soft tissue is needed. Care is exercised in shaping bone ends. Internal fixation can help achieve union if infection was mild. Severe infections need external fixation use in a second stage. Compression at nonunion site achieves union. It can be combined with a corticotomy lengthening at a distant site for equalization. Soft tissue deficit has to be covered by flaps, either local or microvascular. Bone gaps are best filled with the reliable technique of bone transport. Regenerate bone may be formed proximally, distally, or at both sites. Acute compression can fill bone gaps and may need a fibular resection. Gradual reduction of bone gap happens with bone transport, without need for fibulectomy. When bone ends dock, union may be achieved by vertical or horizontal compression. Biological stimulus from iliac crest bone grafts, bone marrow aspirate injections, and platelet concentrates hasten union. Bone graft substitutes add volume to graft and help fill defects. Addition of rh-BMP-7 may help in healing albeit at a much higher cost. Regeneration may need stimulation and augmentation. Induced membrane technique is an alternative to bone transport to fill gaps. It needs large amounts of bone graft from iliac crest or femoral canal. This is an expensive method physiologically and economically. Infection can resorb the graft and cause failure of treatment. It can be done in select cases after thorough eradication of infection. Patience and perseverance are needed for successful resolution of infection and achieving union.