An observational case series of HIV-positive patients treated with open reduction internal fixation for a closed lower extremity fracture

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.

Femoral Neck Fractures in HIV-Positive Patients: Analysis of 10 Years Short-Term Post-operative Complications

Introduction:

Aging and effect of antiretroviral therapy on bone mass could increase the risk of femoral neck fractures (FNF) in HIV patient. The aim of this study was specifically to determine whether intracapsular FNF in HIV-positive patients are more prone to short-term post-operative complications than similar fractures occurring in HIV-negative patients.

Materials and methods:

A group of 25 HIV-positive patients with intracapsular FNF were enrolled and matched to HIV-negative patient with similar fractures according to gender, age, a modified Charlson Comorbidity Index (CCI), fracture classification, surgical treatment and time interval between fracture event and surgery. For each group, length of stay, surgical time, early clinical outcomes and short-term surgical and medical complications were compared to determine the impact on the early outcome.

Results:

At the time of the fracture occurrence, 56% of HIV-positive patients were on antiretroviral therapy and 12% started with therapy in the perioperative period. At three months follow-up, there were no statistically significant differences between the two study groups in length of stay, Harris hip score and total number of early complications. However, a statistically significant increase in urinary tract infections and longer surgical time using hip sliding screw fixation were seen in the HIV-positive group. The poorest post-operative result was seen in a patient who failed to adequately adhere to the HIV therapy protocol.

Conclusions:

This study failed to show any statistically significant increase in short-term complications or worse clinical outcomes for intracapsular FNF in HIV-positive patients compared to HIV-negative patients to recommend their treatment in dedicated centres.

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.

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.

HIV in Orthopaedic Surgery

The emergence of HIV in the United States has had important implications in the surgical setting. This blood-borne pathogen poses risks to both the surgeon and the patient undergoing an orthopaedic procedure. Although there has been research regarding the likelihood of orthopaedic surgeons contracting HIV during a surgical procedure, the correlation of HIV with postoperative prognosis has not been extensively examined. Because HIV-positive patients may be immunodeficient, they are at increased risk for certain postoperative complications, especially infection. Orthopaedic surgeons should have a thorough understanding of the effects of this disease on patients to optimize preoperative decision making, intraoperative care, and postoperative recovery.

Predisposing factors for recurrence of chronic posttraumatic osteomyelitis: a retrospective observational cohort study from a tertiary referral center in Brazil

BACKGROUND

The incidence of posttraumatic osteomyelitis (PTO) is increasing despite new treatment strategies. Assessment of patients' outcomes following PTO is challenging due to multiple variables. The study goals are to determine the frequency of recurrence following PTO treatment and identify factors predisposing patients to treatment failure.

METHODS

Between August 01, 2007 to August 30, 2012, a single-center retrospective cohort study was performed among 193 patients diagnosed with PTO following orthopedic surgery for fracture care. Bone and soft tissues were collected for cultures and PTO was defined according to CDC/NHSN criteria. Patient, injury, surgery-associated variables, and microbiological records were reviewed for risk factors associated to recurrence of PTO. Univariate and multivariable analyses using logistic regression were performed, with p <0.05 considered significant.

RESULTS

Thirty-eight patients (20%) of 192 diagnosed and treated for PTO failed their treatment. Factors associated with recurrence were age between 61 and 80 years [hazard ratio (HR) = 6.086, 95% confidence interval (CI) = 2.459;15.061, p = <0.001], age above 80 years [HR = 9.975 (95% CI = 3.591;27.714), p = <0.001], intraoperative blood transfusion [HR = 2.239 (95% CI = 1.138;4.406), p = 0.020], and positive culture for Pseudomonas aeruginosa [HR = 2.700 (95% CI = 1.370;5.319), p = 0.004].

CONCLUSIONS

Risk factors associated with recurrence of PTO are difficult to measure. The present study revealed that elderly patients, intraoperative blood transfusions, and infection due to P. aeruginosa were independently associated with recurrence of PTO. These factors should warn clinicians of a higher failure rate following treatment of PTO. Trial registration: ISRCTN71648577. Registered 18 May 2017. Retrospectively registered.

The "Road to Union" protocol for the reconstruction of isolated complex high-energy tibial trauma

INTRODUCTION

The purpose of this study was to describe a standardized staged approach, "The Road to Union", for the reconstruction of isolated complex tibial trauma, both acute and chronic in nature.

METHODS

This retrospective study included all patients treated for complex tibial trauma at a specialized limb reconstruction centre, including acute open fracture as well as infected and aseptic non-unions. This standardized approach includes eight specific steps, employed in sequence. The time in external fixation (EFT), the external fixation index (EFI), and the distraction consolidation index (DCI) were the primary outcome measures. The relationship between EFI and DCI was assessed using Pearson's moment correlations.

RESULTS

Thirty-two patients with a mean age of 34.7±14.2years were included; 12 were treated for complex open tibial fractures with bone loss, 13 for infected non-unions, and 6 for aseptic non-union. The mean bone defect was 66±32mm. The total EFT was 42.5±14.8 weeks; the EFI measured 51.9±25.3 days/cm, and the DCI measured 48.3±21.4 days/cm. Union was achieved in 29 out of 32 patients (91%), and there was a strong and significant relationship between EFI and DCI (r=0.92, p=0.0001) measurements. Pin site infections were observed in 11 patients, and 3 patients had persistent non-union. Three patients underwent delayed amputations when reconstructive procedures were unable to achieve union.

CONCLUSION

The findings of this study demonstrate that a standardized staged treatment protocol of debridement, circular external fixation, soft-tissue management, distraction osteogenesis, and functional rehabilitation can result in a high rate of union in cases of complex tibial trauma, both acute and chronic in nature.

LEVEL OF EVIDENCE

Level IV; case series.

Fracture management in HIV positive individuals: a systematic review

PURPOSE

Human immunodeficiency virus (HIV) infection could potentially play an important role in the management of fractures as they have been shown to affect fracture healing and the post-operative risk of implant sepsis.

METHODS

A systematic review of the relevant literature was performed on PubMed and Scopus databases. Twenty-six studies were identified, critiqued and analysed accordingly. No randomised controlled trials were identified.

RESULTS

HIV positivity was not shown to influence an individual's risk of early wound infection in operatively managed closed fractures. The rate of pin track infection in open injuries managed with external fixators was low. However, in open injuries managed with internal fixation, early wound infection rates were increased in the HIV-positive population compared to HIV-negative individuals. Regarding late implant infection, in closed fractures there appeared to be no increased risk of infection but there is limited evidence for open injuries. Additionally, further evidence is needed to establish if the rate of union in both open and closed fractures are influenced by HIV status.

CONCLUSION

Overall, no evidence was found to suggest that surgical management of fractures in the HIV population should be avoided, and fixation of closed fractures in the HIV population appeared to be safe. The effect of anti-retroviral therapy is unclear and this should be further researched. However, based on the limited evidence, caution should be taken in the management of open fractures due to the potentially increased infection risk. The impact of anti-retroviral therapy on the outcomes of surgery needs further evaluation.

Nonunion of the Femur and Tibia: An Update

Delayed union and nonunion of tibial and femoral shaft fractures are common orthopedic problems. Numerous publications address lower extremity long bone nonunions. This review presents current trends and recent literature on the evaluation and treatment of nonunions of the tibia and femur. New studies focused on tibial nonunion and femoral nonunion are reviewed. A section summarizing recent treatment of atypical femoral fractures associated with bisphosphonate therapy is also included.