Open tibia fractures in HIV positive patients

Abstract

Open tibia fractures are common injuries, particularly in developing countries.Pedestrian or bicycle to motor car contact is the most common mechanism.These injuries result in high morbidity and often long-term disability.HIV infection complicates open fractures by raising the incidence of infectionin the open wound (5 of 7 patients in our series). This risk may be compounded if internal fixation techniques are used (5 of 12 HIV patients with internal fixation of any open fracture). There is also a suggestion that HIV may delay bone union (4 of 7 patients united at 6 months). External fixation offers an alternative method of fracture stabilisation. It avoids the risks associated with putting metal-ware in the wound, but creates a new issue of pin track sepsis. We found that pin track infection was more common in patients with HIV, but the rate at which pins required removal was 7%. We consider external fixation to be a lower-risk strategy than internal fixation in such patients but open fracture wound sepsis remains a problem. We have not yet demonstrated a difference in severity or frequency of complications in patients of low CD4 count, but logically one expects septic complications to increase as CD4 count falls. Antiretroviral medication decreases viral load and elevates the CD4 count. Research is underway regarding potential effectiveness of such drugs in reducing wound and fracture healing complications. Above all, meticulous and timely all-round care is required to achieve satisfactory results in immunecompromised patients. This includes, debridement, bony stability, and soft-tissue reconstruction.

The Ortho-Plastic Approach to Soft Tissue Management in Trauma

“…Likewise, HIV infection has been shown to increase the risk of infection and may alter the ultimate decision regarding type and timing of soft tissue and bone fixation [ 135 ].…”

A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2

“…121 Smoking cessation should be encouraged. Immune system diseases such as HIV infection also increase the risks of surgical site infections 130 as do autoimmune diseases such as Rheumatoid Arthritis. 123 These can be managed medically but cannot be eliminated as risk factors.…”

Current concepts in the management of open tibia fractures

“…internal fixation of open tibias was associated with a higher risk of infection; HIV was associated with delayed union; and that HIVpositive patients had a higher rate of pin-tract sepsis with the use of external fixation. 118 However, there are a number of factors limiting the validity of their findings: the presence of confounding factors such as smoking, nutrition, small patient number in all the studies and, probably most importantly, CD4 count.…”

“…117 Harrison et al conducted three studies relevant to this topic: a prospective study of open tibia fractures comparing HIV-positive and -negative patients; a prospective study of internal fracture fixation including cases in open fractures comparing wound infection for HIVpositive and -negative patients; and a prospective study of pin-tract sepsis comparing HIV-positive and -negative patients. 117,118 They found that rates of infection were higher in HIV-positive patients;…”

“…These studies were undertaken long before the advent of antiretroviral therapy, and it is plausible that an HIV-infected patient with a normal CD4 may be treated as immune competent. 118 Recent evidence indicates there is no association between HIV status and surgical outcome unless the CD4 count is below 350 cells/ml. [119][120][121][122] It is therefore suggested that HIV status should not influence the management of open tibia fractures.…”