Delayed implants sepsis in HIV-positive patients following open fractures treated with orthopaedic implants

HIV and fracture: Risk, assessment and intervention

OBJECTIVES

With management of comorbidity in people living with HIV (PLWH) a key component of clinical care, early loss of bone integrity and clinical fracture are recognized as important issues. This review aims to describe the epidemiology of fracture in PLWH, as well as summarizing the relative balance of factors that contribute to fracture. We also aim to describe fracture risk assessment and interventional strategies to modify the risk of fracture in this population.

RESULTS

Data from recent meta-analyses show that PLWH have significantly more fractures than the general population, with men and injecting drug users at higher risk. Modifiable factors that contribute to fracture risk in this cohort include body mass index (BMI), drug use, concurrent medications, frailty, and hepatitis C virus infection. Relating to antiretroviral therapy, current or ever tenofovir exposure has been identified as predictive of fracture but not cumulative use, and a potentially modest protective effect of efavirenz has been observed. Fracture Risk Assessment Tool scores underestimate fracture risk in PLWH with improved accuracy when HIV is considered a cause of secondary osteoporosis and bone mineral density (BMD) included.

CONCLUSION

Early consideration of risk, prompting evaluation of modifiable risk factors, frailty and falls risk with bone density imaging and prompt intervention may avert fracture in PLWH. Guidance on screening and lifestyle modification is available in international guidelines. Bisphosphonates are safe and effective in PLWH, with limited data for other agents.

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.

Bacterial Contamination of Open Fractures: Pathogens and Antibiotic Resistance Patterns in East China

Bacterial contamination of soft tissue in open fractures leads to high infection rates. Pathogens and their resistance against therapeutic agents change with time and vary in different regions. The purpose of this study was to characterize the bacterial spectrum present in open fractures and analyze the bacterial resistance to antibiotic agents based on five trauma centers in East China. A retrospective multicenter cohort study was conducted in six major trauma centers in East China from January 2015 to December 2017. Patients who sustained open fractures of the lower extremities were included. The data collected included the mechanism of injury, the Gustilo-Anderson classification, the isolated pathogens and their resistance against therapeutic agents, as well as the prophylactic antibiotics administered. In total, 1348 patients were included in our study, all of whom received antibiotic prophylaxis (cefotiam or cefuroxime) during the first debridement at the emergency room. Wound cultures were taken in 1187 patients (85.8%); the results showed that the positive rate of open fracture was 54.8% (651/1187), and 59% of the bacterial detections occurred in grade III fractures. Most pathogens (72.7%) were sensitive to prophylactic antibiotics, according to the EAST guideline. Quinolones and cotrimoxazole showed the lowest rates of resistance. The updated EAST guidelines for antibiotic prophylaxis in open fracture (2011) have been proven to be adequate for a large portion of patients, and we would like to suggest additional Gram-negative coverage for patients with grade II open fractures based on the results obtained in this setting in East China.

Telemedicine in Surgical Care in Low- and Middle-Income Countries: A Scoping Review

Background

Access to timely and quality surgical care is limited in low- and middle-income countries (LMICs). Telemedicine, defined as the remote provision of health care using information, communication and telecommunication platforms have the potential to address some of the barriers to surgical care. However, synthesis of evidence on telemedicine use in surgical care in LMICs is lacking.

Aim

To describe the current state of evidence on the use and distribution of telemedicine for surgical care in LMICs.

Methods

This was a scoping review of published and relevant grey literature on telemedicine use for surgical care in LMICs, following the PRISMA extension for scoping reviews guideline. PubMed-Medline, Web of Science, Scopus and African Journals Online databases were searched using a comprehensive search strategy from 1 January 2010 to 28 February 2021.

Results

A total of 178 articles from 53 (38.7%) LMICs across 11 surgical specialties were included. The number of published articles increased from 2 in 2010 to 44 in 2020. The highest number of studies was from the World Health Organization Western Pacific region (n = 73; 41.0%) and of these, most were from China (n = 69; 94.5%). The most common telemedicine platforms used were telephone call (n = 71, 39.9%), video chat (n = 42, 23.6%) and WhatsApp/WeChat (n = 31, 17.4%). Telemedicine was mostly used for post-operative follow-up (n = 71, 39.9%), patient education (n = 32, 18.0%), provider training (n = 28, 15.7%) and provider-provider consultation (n = 16, 9.0%). Less than a third (n = 51, 29.1%) of the studies used a randomised controlled trial design, and only 23 (12.9%) reported effects on clinical outcomes.

Conclusion

Telemedicine use for surgical care is emerging in LMICs, especially for post-operative visits. Basic platforms such as telephone calls and 2-way texting were successfully used for post-operative follow-up and education. In addition, file sharing and video chatting options were added when a physical assessment was required. Telephone calls and 2-way texting platforms should be leveraged to reduce loss to follow-up of surgical patients in LMICs and their use for pre-operative visits should be further explored. Despite these telemedicine potentials, there remains an uneven adoption across several LMICs. Also, up to two-thirds of the studies were of low-to-moderate quality with only a few focusing on clinical effectiveness. There is a need to further adopt, develop, and validate telemedicine use for surgical care in LMICs, particularly its impact on clinical outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06549-2.

Are deep infections that present before and after 90 days from orthopaedic trauma different? An analysis of the validity of the recent change in CDC criteria for infections

BACKGROUND

In 2016, the Centers for Disease Control and Prevention (CDC) changed the time frame for their definition of deep surgical site infection (SSI) from within 1 year to within 90 days of surgery. We hypothesized that a substantial number of infections in patients who have undergone fracture fixation present beyond 90 days and that there are patient or injury factors that can predict who is more likely to present with SSI after 90 days.

METHODS

A retrospective review yielded 452 deep SSI after fracture fixation. These patients were divided into two groups-those infected within 90 days of surgery and those infected beyond 90 days . Data were collected on risk factors for infection. Univariate and multiple logistic regression analyses were performed to compare the two groups. A randomly selected control group was used to build infection prediction models for both outcomes. The two outcomes were then modelled against each other to determine whether differences in predictors for early versus late infection exist.

RESULTS

Of the 452 infections, 144 occurred beyond 90 days (32% [95% CI, 28%-36%]). No statistically significant patient factors were found in multivariable analysis between the early and late infection groups. The need for flap coverage was the only injury characteristic that differed significantly between groups, with patients in the late infection group more likely to have needed a flap. When modelled against the control group and directly comparing the two models, predictors for early infection include male sex and fractures of the pelvis, acetabulum, or hip, whereas predictors of late infection include hepatitis C and/or human immunodeficiency virus (HIV) and admission to the intensive care unit (ICU).

CONCLUSION

Use of the recent CDC definition will underestimate the rate of actual postoperative infections when applied to orthopaedic trauma patients. Hepatitis C and/or HIV and ICU admission are predictors of late infection, whereas male sex and pelvis, acetabulum, or hip fractures are predictors of early infection. Patients who receive flap coverage may be more likely to present with late infection.

The importance of anatomical reduction in the functional outcome of open ankle fractures

INTRODUCTION

Whilst closed ankle fracture injuries are common, well characterized and have treatment guidelines derived from the literature, open ankle fractures are rare and are not well studied. The few studies that exist are from the developed First World and these well resourced circumstances are not available in most parts of the world. The purpose of this prospective study was to assess the functional outcomes of open ankle fractures and the factors associated with their outcome in an adult population in rural South Africa.

METHODS

This prospective study was done at a referral hospital in a rural and semi-rural part of South Africa during the study period from January 1, 2013 until April 30, 2019 and was a retrospective chart review of 59 adult patients who sustained open ankle fractures. Pre-, peri- and postoperative factors in the chart review were assessed for each patient. Twenty-one patients were available for follow-up and were reviewed at least 6 months post injury for a functional assessment using the American Orthopedic Foot and Ankle Society Score (AOFAS).

RESULTS

The average AOFAS was 68,2 out of 100 (fair outcome). The lowest score recorded was 38 (one patient) and the highest score 95 (two patients). Nine patients presented with a poor outcome (<60), six with a fair outcome (60-79), two with a good outcome (80-89) and four with an excellent outcome (90-100). The only significant finding, using a Fisher's exact test, indicated that anatomical reduction of the fracture lead to a fair, good or excellent outcome compared to a non-anatomical reduction leading to a poor functional outcome (p = 0,046).

CONCLUSIONS

Our results showed that open ankle fractures are serious injuries with a very variable outcome when managed in a rural or semi-rural setting and that anatomical reduction is required to achieve an optimal functional outcome.

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.

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.

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.

Early Outcomes of Primary Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Patients with Human Immunodeficiency Virus in China

Background:

Studies have reported that patients with human immunodeficiency virus (HIV) have a high incidence of osteonecrosis of the femoral head (ONFH). Total hip arthroplasty (THA) is an effective management of ONFH. However, little data exist regarding the use of THA for the HIV patients with ONFH in China. This study reviewed the outcomes of HIV-positive patients who underwent THA for ONFH, compared with HIV-negative individuals.

Methods:

The patients who underwent THA for ONFH from September 2012 to September 2014 in Beijing Ditan Hospital, Capital Medical University were retrospectively studied. Twenty-eight HIV-positive patients and 35 HIV-negative patients underwent 48 THAs and 45 THAs with cementless components, respectively. Medical records and follow-up data were reviewed. Harris Hip Score (HHS) was applied to evaluate the pain and function of the hips before and after THA. Complications such as wound healing, surgical site infection, deep venous thrombosis, pulmonary embolism, sepsis, mortality, and complications from the prosthesis were reviewed. The operation time, blood loss, and hospital stay were compared between the two groups.

Results:

The mean follow-up period was 19.5 ± 5.8 months (ranging from 6 to 30 months). The mean age of the HIV-positive patients with osteonecrosis at the time of surgery was 35 years old, which was significantly lower than that of the HIV-negative group (42 years old) (P < 0.05). The HIV-positive patients underwent surgery a mean of 2.5 years after their original symptoms, which was significantly shorter than the HIV-negatives’ (mean 4 years) (P < 0.05). Among HIV-positive patients, the prevalence of being male and rate of bilateral procedures were significantly higher than those in the HIV-negative group (P < 0.05). The operation time in HIV-positive patients was significantly longer than that in HIV-negative patients (P < 0.05). There were no significant differences in blood loss or hospital stay between the two groups (P > 0.05). The HHSs of two groups significantly improved after THAs (P < 0.05), without significant difference between two groups. No wound complication, sepsis, mortality, prosthesis complication, and occupational exposure occurred, except for two cases of heterotopic ossification and one case of humeral head necrosis.

Conclusions:

ONFH is more likely to occur bilaterally in younger HIV-positive males. The development of osteonecrosis seems faster in HIV-positive patients than in HIV-negative patients. This should be cautionary for asymptomatic HIV-positive patients with low viral RNA level and in the primary HIV stage. Despite longer operation times in the HIV-positive patients than in the HIV-negative patients, THA is still a safe and efficient approach to treat ONFH in HIV-positive patients. The incidence of complications is much lower than previously reported. However, the long-term follow-up is needed.

Bacterial contamination of open fractures - pathogens, antibiotic resistances and therapeutic regimes in four hospitals of the trauma network Cologne, Germany

INTRODUCTION

The bacterial contamination of soft tissues and bone in open fractures leads to an infection rate of up to 50%. Pathogens and their resistance against therapeutic agents change with time and vary in different regions. In this work, our aims were to characterize the bacterial spectrum present in open fractures, analyze the bacterial resistance to antibiotic agents and question the EAST guideline recommendations for antibiotic prophylaxis after open fractures in a German Trauma Network.

MATERIALS AND METHODS

We conducted a retrospective cohort study and included all patients with open fractures from 1(st) of January 2011 until the 31(st) of December 2014 in four hospitals of the trauma network cologne. Soft tissue damage was classified according to the Gustilo Anderson classification.

RESULTS

We included 123 patients. Forty-five injuries (37%) were classified I°, 45 (37%) as II° and 33 (27%) as III°. Lower leg (34%) was the most commonly injured location. An antibiotic prophylaxis was administered to 109 patients (89%). In 107 of them (98%) a cephalosporin or cephalosporin combination was given. In 35 of the patients (28%), microbiological samples were taken of the fracture site. Wound cultures were positive in 21 patients (60%). Fifty percent of the bacterial detections occurred in III° fractures. Coagulase negative Staphylococci (COST) were the most frequent pathogens. In II° open fractures one gram-negative strain was isolated. Fewest resistances were seen against quinolones and co-trimoxazole.

DISCUSSION

The recommended EAST guideline prophylaxis would have covered all but one bacterium (97% of positive cultures). One Escherichia coli was found in a II° open fracture and would have been missed. One of the isolated Staphylococci epidermidis and an Enterococcus faecium were resistant against gentamycin and first- and second-generation-cephalosporin's which were used as prophylaxis frequently. However, a regional adaption of the EAST guidelines seems not justified due to the rather low number of cases in our study.

CONCLUSION

The EAST guideline seems to be adequate in a high percentage of cases (97%) in the setting of the trauma network cologne. Further research should be guided at identification of initial open fracture pathogens to improve the efficiency of antibiotic prophylaxis.