We report a prospective single-blind controlled study of the incidence of early wound infection after internal fixation for trauma in 609 patients, of whom 132 were HIV-positive. Wounds were assessed for healing using the ASEPSIS score. There was no significant difference in the rate of infection between HIV-positive and HIV-negative patients undergoing clean surgery (4.2% vs 6%, respectively; p = 0.65). HIV-positive patients did not receive additional antibiotic prophylaxis or antiretroviral therapy as part of their management. The difference in the rate of infection between HIV-positive and HIV-negative patients with an open fracture or other contamination was not significant (33% vs 15%, respectively; p = 0.064). There was no relationship between CD4 count and infection rate. HIV status did not significantly influence the number of secondary surgical procedures (p = 0.183) or the likelihood of developing chronic osteomyelitis (p = 0.131). Although previous contamination from the time of injury was a risk factor for infection in mal- and nonunions, it was not significantly increased in HIV-positive patients (p = 0.144). We conclude that clean implant surgery in HIV-positive patients is safe, with no need for additional prophylaxis

Fractures of the ankle are common, and they mostly affect young adults. Wound complications are not uncommon following the fixation of these fractures. This study evaluated the impact of HIV on wound healing after plate osteosynthesis in patients with closed ankle fractures. This is an observational retrospective study of patients operated on at a tertiary level hospital. We reviewed hospital records for patients above 18 years of age who presented with wound breakdown following ankle open reduction and internal fixation. The patients’ hospital records were retrieved to identify all the patients treated for closed ankle fractures and those who developed wound breakdown. Patients with Pilon fractures were excluded. The National Health Laboratory System (NHLS) database was accessed to retrieve the CD4 count, viral load, haematology study results, and biochemistry results of these patients at the time of surgery and subsequent follow-up. The x-rays were retrieved from the electronic picture archiving system (PACS) and were assessed for fracture union at a minimum of 3 months follow-up. We reviewed the medical records of 172 patients with closed ankle fractures treated from 2018 to 2022. Thirty-one (18.0%) developed wound breakdown after surgery, and they were all tested for HIV. Most of the patients were male (58.0%), and the average age of the cohort was 43.7 years (range: 21 years to 84 years). Ten of these patients (32.2%) were confirmed HIV positive, with CD4 counts ranging from 155 to 781. Viral load levels were lower than detectable in 40% of these patients. All patients progressed to fracture union at a minimum of 3 months follow-up. We observed no difference between HIV-positive and HIV-negative patients in terms of wound breakdown and bone healing post-plate osteosynthesis for closed ankle fractures

We studied 51 patients with osteo-articular tuberculosis who were divided into two groups. Group I comprised 31 newly-diagnosed patients who were given first-line antituberculous treatment consisting of isoniazid, rifampicin, ethambutol and pyrazinamide. Group II (non-responders) consisted of 20 patients with a history of clinical non-responsiveness to supervised uninterrupted antituberculous treatment for a minimum of three months or a recurrence of a previous lesion which on clinical observation had healed. No patient in either group was HIV-positive. Group II were treated with an immunomodulation regime of intradermal BCG, oral levamisole and intramuscular diphtheria and tetanus vaccines as an adjunct for eight weeks in addition to antituberculous treatment. We gave antituberculous treatment for a total of 12 to 18 months in both groups and they were followed up for a mean of 30.2 months (24 to 49). A series of 20 healthy blood donors served as a control group. Twenty-nine (93.6%) of the 31 patients in group I and 14 of the 20 (70%) in group II had a clinicoradiological healing response to treatment by five months. The CD4 cell count in both groups was depressed at the time of enrolment, with a greater degree of depression in the group-II patients (686 cells/mm. 3. (. sd. 261) and 545 cells/mm. 3. (. sd. 137), respectively; p < 0.05). After treatment for three months both groups showed significant elevation of the CD4 cell count, reaching a level comparable with the control group. However, the mean CD4 cell count of group II (945 cells/mm. 3. (. sd. 343)) still remained lower than that of group I (1071 cells/mm. 3. (. sd. 290)), but the difference was not significant. Our study has shown encouraging results after immunomodulation and antituberculous treatment in non-responsive patients. The pattern of change in the CD4 cell count in response to treatment may be a reliable clinical indicator

The results of primary total knee replacement performed on a group of haemophiliac patients in a single institution by the same surgeon using the same surgical technique and prosthesis are reported. A total of 35 primary replacements in 30 patients were carried out between 1996 and 2005 and were reviewed retrospectively. The mean age of the patients was 31 years (24 to 42) and the mean follow-up was for 7.5 years (1 to 10). There were 25 patients with haemophilia A and five with haemophilia B. The HIV status and CD4 count were recorded, and Knee Society scores determined. Two patients had inhibitors to the deficient coagulation factor. There were no early wound infections and only one late deep infection which required a two-stage revision arthroplasty, with a good final result. The incidence of infection in HIV-positive and negative patients was thus similar. One knee in a patient with inhibitor had excessive bleeding due to a pseudoaneurysm which required embolisation. The results were excellent in 27 knees (77%), good in six (17%) and fair in two (6%). The survival rate at 7.5 years taking removal of the prosthesis for loosening or infection as the end-point was 97%. The mechanical survival of total knee replacements in haemophiliacs is very good. Our results confirm that this is a reproducible procedure in haemophilia, even in HIV-positive patients with a CD4 count > 200 mm. 3. and those with inhibitors. Our rate of infection was lower than previously reported. This could be due to better control of the HIV status with highly active anti-retroviral therapy and the use of antibiotic-loaded cement

Aims. HIV predisposes patients to opportunistic infections. However, with the establishment of Highly Active Anti-Retroviral Therapy (HAART), patients’ CD4 counts are maintained, as is a near normal life expectancy. This study aimed to establish the impact of HIV on the bacteriology of spondylodiscitis in a region in which tuberculosis (TB) is endemic, and to identify factors that might distinguish between them. Patients and Methods. Between January 2014 and December 2015, 63 consecutive cases of spontaneous spondylodiscitis were identified from a single-centre, prospectively maintained database. Demographics, presenting symptoms, blood results, HIV status, bacteriology, imaging, and procedure undertaken were reviewed and comparisons made of TB, non-TB, and HIV groups. There were 63 patients (22 male, 41 female) with a mean age of 42.0 years (11 to 78; . sd. 15.0). Results. In total, 53 patients had tuberculous, nine bacterial, and one cryptococcal spondylodiscitis. There were 29 HIV-positive patients, 29 HIV-negative patients, and five patients with unknown HIV status. The local incidence of TB spondylodiscitis was 1.54/100 000 and that of non-TB spondylodiscitis was 0.29/100 000 per annum. TB patients were younger with similar clinical presentation and infective markers, but were more likely to have a paraspinal abscess. They were also less likely to have a hyperintense disc on MRI. There was no difference between the two HIV groups. Conclusion. In areas of endemic TB and HIV, TB remains the most common cause of spondylodiscitis at five times the rate of non-tuberculous causes. HIV managed with HAART increases the rate of infection but does not influence the bacteriology unless there is a low CD4. There was little to differentiate the groups. TB /HIV co-infected patients were younger than non-TB and HIV-negative patients. Non-TB patients were more likely to have disc hyperintensity on MRI and TB patients were more likely to have abscess formation, but as both groups exhibited these features, neither was diagnostic. Culture confirmation remains necessary. Cite this article: Bone Joint J 2019;101-B:617–620

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

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

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. Methods:. From February 2011 until November 2012 all patient with closed femoral shaft fractures treated at our hospital were included in the study. Patients were tested for HIV infection and a number of clinical parameters were documented, including: AO fracture score, duration of surgery, level of training of surgeon, comorbidities, CD4 count, high energy injury and number of operations. Results:. Forty (25%) patients were HIV positive. Seven patients had CD4 counts below 350 cells/µL and 12 patients were on ARV's. Four (3%) patients developed implants sepsis and of these 1 (25%) was HIV positive. Two (1%) patients had a delayed union of more than 6 months and both these patients were HIV negative. Conclusion:. HIV is not a risk factor for delayed union and implant sepsis in the first 12 months after surgery. Intramedullary nailing is a safe and effective in the treatment of HIV positive patients with closed femur fractures

A prospective study was undertaken of wound healing in HIV positive patients undergoing orthopaedic implant surgery. 175 implant operations were assessed. 40 operations (23%) were in HIV positive individuals. Wounds were scored using the Asepsis scoring system. Closed fractures in HIV positive patients had 1 (3. 5%) major infection. No correlation was seen between CD4 count and risk of wound infection. With regards to early wound sepsis, implant surgery can be undertaken safely in HIV positive individuals with closed injuries regardless of CD4 count. The risk of wound sepsis rises dramatically in implant surgery for HIV positive patients with open fractures

Introduction. The resurgence of TB worldwide has several underlying causes, but HIV infection has undoubtedly been a key factor in the current TB epidemic. Since TB is endemic in the developing world the influence of HIV is of concern, particularly with the emergence of multi-drug-resistant strains. The remarkable susceptibility of patients with AIDS to develop TB has shown the critical role of CD4 lymphocytes in protective immunity. In the absence of immunological surveillance by CD4 cells, 5-10% of persons with latent foci of TB reactivate each year. Aim. This paper highlights the presentation and outcome following treatment in HIV patients with spinal TB. Methods. 81 HIV+ve patients with spinal tuberculosis were prospectively evaluated between 2006 and 2007. The mean age was 31 years and 63% were females. The thoracic spine was affected in 45, lumbar (33) and cervical (3). Non-contiguous lesions were noted in six patients. Sixty-six (81%) patients had neurological deficit. The mean Hb was (10.1gm/dl), mean WCC 4.9, mean lymphocyte count was 1.8, mean ESR 79mm/h and the mean CD4 count was 268 cell/cumm. Co-morbidities were seen in 68% of patients. All patients were optimised prior to treatment. Posterolateral decompression was performed in 29 cases, anterior decompression (25), needle biopsy (13), incision and drainage 5 and 9 were treated non-operatively. Medication included ARV (72 patients) and anti-TB in all patients. Results. The mean follow-up was 21 months. Eleven (13.5%) patients developed wound infection and one child died. Complete recovery occurred in 23 patients (35%). The mean CD4 count was 341 cell/cumm. Conclusion. The short term results are encouraging. These patients are best managed by a multidisciplinary team to monitor potential complications from dual therapy, to ensure compliance and adequate nutrition

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;. Open fractures in HIV positive patients can be managed to union with internal fixation;. That in may not be appropriate to leave grade 1 injuries in HIV positive patients for non urgent debridement/fixation, as 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

We present a rare case of multifocal Proteus mirabilis osteomyelitis in an HIV-positive patient. Despite the patient’s good immune status as assessed by her CD4 cell count and the aggressive treatment, she eventually underwent bilateral above-knee amputations to eradicate the infection. Multifocal Proteus mirabilis osteomyelitis can have an unpredictable clinical course with a severe outcome in HIV-positive patients

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. Results. Twenty eight patients were incorporated over a six month period and followed up for three months post operatively. 25 open fractures including 6 HIV positive patients and 3 closed fractures including 1 HIV positive patient were assessed for signs of wound sepsis assessed with the asepsis wound score. 21 patients treated with external fixation including 4 HIV positive patients were also assessed using Checkett's scoring system for pin site infection. There was no significant difference in post-operative wound infection rates between the HIV positive (mean wound score = 7.7) and HIV negative (mean = 3.7) patients (p=0.162). HIV positive patients were also found to be at no increased risk of pin site sepsis (p=0.520). No correlation was found between CD4 counts of HIV positive patients and wound infection rates. Conclusions. Our results show that HIV positive patients with tibial fractures are not significantly more at risk of wound infection postoperatively. External fixation has also been shown to be a safe effective treatment of open tibial fractures in HIV patients

There is increasing awareness of and concern about the treatment of HIV-infected patients with painful joint arthropathy. Orthopaedic surgeons and hospitals face the challenge of providing optimal treatment in the most cost effective way. The purpose of this study was to determine the most effective way of treating arthropathy in HIV-infected patients and to document the complications. Twelve HIV-positive patients with a mean age of 45 years underwent THA. Assessment of nutritional status showed a mean serum albumen of 300 g/l. The mean haemoglobin was 11. The ESR was elevated in all cases, with a mean of 92 mm/hour Westergren and mean CD4 count of 455. At follow-up (mean 36 months) all patients were fully ambulant, with no signs of infection. Nevertheless, the decision to perform total joint replacement in HIV-positive patients should be taken with utmost care. The outcome depends on a number of factors, including nutritional status, coexisting medical problems and the stage of the disease

This study was undertaken to determine the most effective way of treating intracapsular femoral neck fractures in HIV-positive patients. Ten patients with a mean age of 36 years were treated. Excision Girdlestone was performed In three patients in whom previous internal fixation had failed: all had poor nutritional status and low CD4 counts (mean 162). Three patients with undis-placed fractures were treated with percutaneous AO screws and a dynamic hip screw. In the remaining four patients, total hip arthroplasty (THA) was performed. At a mean follow-up of 14 months, all patients were fully ambulant with no signs of infection. The decision to proceed with THA in HIV-positive patients should be made only after weighing the ratio of risks and benefits. The ultimate outcome depends on a number of factors, including displacement of fractures, previous surgery, co-existent medical problems, nutritional status and the stage of the disease

HIV and musculoskeletal trauma have reached epidemic proportions in the developing world especially in sub Saharan Africa. The epidemic has adversely affected health care delivery in limited resource settings. We assessed the outcome of HIV+ patients following spinal surgery for fractures and dislocations. Forty seven HIV+ patients were treated surgically over the past three years. The mean age was 32 years (19–53 years) and included 39 males. The dorsolumbar region was affected in 28 patients and the cervical spine in 19. Motor vehicle collisions (34) accounted for 72% of the injuries. Neurology occurred in 49% of patients (23). The mean CD4 count was 426 (range 98–742). The albumen was 29 gm/d? (range 26–34) and the lymphocyte count was 1.6c/cumm range 1.4–1.9). Twenty eight patients had generalized lymphadenopathy and recent weight loss was noted in 11 patients. Fifteen patients were treated for pulmonary TB and seven patients were on ARVs. The dislocations at the cervical spine commonly occurred at C5/6 (8). Three patients required a posterior cervical release with facetectomy prior to anterior cervical plating which was performed in all patients. The dislocations and unstable burst fractures of the dorsolumbar spine were treated by a one/two level posterior fusion. Post-operative sepsis due to S. aureus occurred in 8 (17%) patients. In four patients with deep infection vacuum dressings were used to clear the sepsis. Post-operative sepsis is best avoided by optimization of patients and meticulous surgery

We performed a prospective, blind, controlled study on wound infection after implant surgery involving 41 procedures in patients infected with the human immunodeficiency virus (HIV) and 141 in HIV-negative patients. The patients were staged clinically and the CD4 cell count determined. Wound infection was assessed using the asepsis wound score. A risk category was allocated to account for presurgical contamination. In HIV-positive patients, with no preoperative contamination, the incidence of wound infection (3.5%) was comparable with that of the HIV-negative group (5%; p = 0.396). The CD4 cell count did not affect the incidence of infection (r = 0.16). When there was preoperative contamination, the incidence of infection in HIV-positive patients increased markedly (42%) compared with that in HIV-negative patients (11%; p = 0.084). Our results show that when no contamination has occurred implant surgery may be undertaken safely in HIV-positive patients

Introduction. The Human immunodeficiency virus (HIV) has changed all aspects of orthopaedic practice in Durban, South Africa. In our Arthroplasty unit, we have noticed a significant increase in HIV positive patients that required total hip arthroplasty (THR). Method. We conducted a retrospective, demographic chart review of all patients below the age of 55years undergoing primary THR in our unit from 2004 to 2011. Results. The results show a steady rise from 22 THR's in 2004, to 51 in 2011. There was a demographic change in patients presenting with avascular necrosis (AVN) as primary diagnosis, with a significant increase of HIV positive patients. The new demographic group that makes up 44% of our current practice are black Africans, particularly females (70% of all black patients). The majority of them (66%) have none of the previous risk factors for AVN (alcohol, smoking and steroids) and out of this group 52% are HIV positive on anti-retroviral medication (ARV's) with an average CD4 count of 516. All HIV positive patients, in this demographic study, were black African females. Discussion. In the past, the typical patient receiving a primary THR for AVN in Durban was a young Asian male. These patients had strong associations with alcohol, smoking and oral steroid use. This demographic group makes up 33% of our current practice. Demonstrated clearly is a change in demographics of patient population and this lead to a number of interesting questions. What caused this sudden increase in HIV related AVN in our unit? To what extend do ARV's contribute to this accelerated progression of AVN and HIV?. This paper focuses our attention on HIV and its affect in modern orthopaedics. The challenge is great, the question remains … how will we respond?. NO DISCLOSURES

The increased prevalence of HIV has increased awareness and concern for the diagnosis and treatment of patients requiring total joint arthroplasty. Collective experience with HIV and arthroplasty at any institution is small and limited. This study evaluates the clinical outcome of arthroplasty in HIV infected patients. Between July 2000 and August 2001, we treated 14 patients (4 female) and with uncemented total hip replacement. (Mean age of 42 years). Informed consent was obtained before HIV testing and counselling was provided for all patients. Patients were classified according to the WHO and CDC classification. All patients were operated on by a single surgeon using the Hardinge approach. 14 Patients were followed up with a mean follow up 62 months. The pre-lymphycyte subset analysis was TLC-2.24, CD4 425, CD8 873, CD4/CD8-0.52. All patients were fully ambulant. One patient sustained a periprosthetic fracture following a high energy car accident which was treated non operatively. Three patients have dropped their CD4 count to below 200 and are presently receiving antiretroviral treatment. There was no loosening, infection or dislocation. The literature on complications associated with arthroplasty in HIV infected patients is inconsistent. A few authors have reported a 40% incidence of infection with total joint replacement. In this series there were no infections, and the outcome of total joint arthroplasty depends on the nutritional status of the patient, the stage of the under lying disease, as well as previous surgery and co-morbidities. Orthopaedic Surgeons should be aware of the increasing prevalence of HIV infection, and that arthroplasty in these patients can be safely performed with minimum complications

Aims

The incidence of limb fractures in patients living with HIV (PLWH) is increasing. However, due to their immunodeficiency status, the operation and rehabilitation of these patients present unique challenges. Currently, it is urgent to establish a standardized perioperative rehabilitation plan based on the concept of enhanced recovery after surgery (ERAS). This study aimed to validate the effectiveness of ERAS in the perioperative period of PLWH with limb fractures.