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Abbas S, Chokotho L, Nyamulani N, Oliver VL. The burden of long bone fracture and health system response in Malawi: A scoping review. Injury 2024; 55:111243. [PMID: 38096746 DOI: 10.1016/j.injury.2023.111243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 01/29/2024]
Abstract
OBJECTIVES Fractures pose serious health and socioeconomic consequences for individuals, their families, and societies more broadly. In many low-resource settings, case fatality and long-term sequelae after a fracture remain high due to individual- and system-level barriers affecting timely access to care. This scoping review explored the burden of fractures in Malawi using long bone fracture (LBF) as a case study by examining the epidemiology of these injuries, their consequences, and the accessibility of quality healthcare. Our aim is to not only describe the scale of the issue but to identify specific interventions that can help address the challenges faced in settings with limited resources and healthcare budgets. METHODS A scoping review methodology was adopted with a narrative synthesis of results. We searched five databases to identify relevant literature and applied the "Three Delays" model and the WHO's Building Blocks Framework to analyse findings on the accessibility of fracture care. RESULTS Fractures most often occurred among young males, with falls being the leading cause, constituting between 5 and 35 % of the total burden of injuries. Fractures were typically managed without surgery despite consistent local evidence showing surgical treatment was superior to conservative management in terms of length of hospital stay and bone healing. Poor functional, economic, and social outcomes were noted in fracture patients, especially after conservative treatment. A lack of trust in the health system, financial barriers, poor transport, and road infrastructure, and interfacility transfers were identified as barriers to care-seeking. Factors challenging the provision of appropriate care included governance issues, poor health infrastructure, financial constraints, and shortage of supplies and human resources. CONCLUSIONS To the best of our knowledge, this review represents the first comprehensive examination of the state of LBF and the health system's response in Malawi. The findings underscore the pressing need for a national trauma registry to accurately determine the actual burden of injuries and support a tailored approach to fracture care in Malawi. It is further evident that the health system in Malawi must be strengthen across all six building blocks to address obstacles to equitable access to high-quality fracture care.
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Affiliation(s)
- Shazra Abbas
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Australia.
| | - Linda Chokotho
- Malawi University of Science and Technology, Mikolongwe, Malawi
| | | | - Victoria L Oliver
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Australia
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Chen H, Zhu Y, Chen Q. Fracture-related wound infections following surgical treatment of fractures in HIV-positive and HIV-negative patients: A meta-analysis. Int Wound J 2024; 21:e14336. [PMID: 37705307 PMCID: PMC10784629 DOI: 10.1111/iwj.14336] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 09/15/2023] Open
Abstract
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.
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Affiliation(s)
- Huizhen Chen
- Department of EndocrinologyHospital of Chengdu University of Traditional Chinese MedicineChengduChina
| | - Yuxia Zhu
- Infection Management OfficeHospital of Chengdu University of Traditional Chinese MedicineChengduChina
| | - Qiu Chen
- Department of EndocrinologyHospital of Chengdu University of Traditional Chinese MedicineChengduChina
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Graham SM, Maqungo S, Laubscher M, Ferreira N, Held M, Harrison WJ, Simpson AH, MacPherson P, Lalloo DG. Is human immunodeficiency virus a risk factor for the development of nonunion?-a case-control study. OTA Int 2023; 6:e251. [PMID: 37780185 PMCID: PMC10538559 DOI: 10.1097/oi9.0000000000000251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 12/23/2022] [Indexed: 10/03/2023]
Abstract
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.
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Affiliation(s)
- Simon Matthew Graham
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Liverpool Orthopaedic and Trauma Service, Liverpool University Teaching Hospital Trust, Liverpool, UK
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa
| | - Sithombo Maqungo
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa
- Orthopaedic Research Unit (ORU), University of Cape Town, Cape Town, South Africa
- Division of Global Surgery, University of Cape Town, Cape Town, South Africa
| | - Maritz Laubscher
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa
- Orthopaedic Research Unit (ORU), University of Cape Town, Cape Town, South Africa
| | - Nando Ferreira
- Division of Orthopaedic Surgery, Stellenbosch University, Cape Town, South Africa
| | - Michael Held
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa
- Orthopaedic Research Unit (ORU), University of Cape Town, Cape Town, South Africa
| | | | | | - Peter MacPherson
- School of Health & Wellbeing, University of Glasgow, UK
- Clinical Research Department, London School of Hygiene & Tropical Medicine, UK; and
| | - David G. Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Zhao R, Ding R, Zhang Q. 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. AIDS Res Hum Retroviruses 2021; 37:551-556. [PMID: 33386058 DOI: 10.1089/aid.2020.0184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Rugang Zhao
- Department of Orthopedic, Beijing Ditan Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Emerging Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Rui Ding
- Center of Liver Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Qiang Zhang
- Department of Orthopedic, Beijing Ditan Hospital, Capital Medical University, Beijing, China
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A tale of three pandemics: Shining a light on a hidden problem. Surgeon 2021; 20:231-236. [PMID: 34167911 PMCID: PMC9300845 DOI: 10.1016/j.surge.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/12/2021] [Accepted: 04/28/2021] [Indexed: 11/23/2022]
Abstract
An “epidemic” is an event in which a disease, infectious or non-infectious, is actively spreading within a population and designated area. The term “pandemic” is defined as “an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people”. The global response to the COVID-19 pandemic has not been seen since the outbreak of Human Immunodeficiency Virus in the early eighties. But there is another unseen pandemic running alongside the current COVID-19 pandemic, which affects a vast number of people, crossing international boundaries and occurring in every single country worldwide. The pandemic of traumatic injuries. Traumatic injuries account for 11% of the current Global Burden of Disease, resulting in nearly 5 million deaths annually and is the third-leading cause of death worldwide. For every trauma-related death, it is estimated that up to 50 people sustain permanent or temporary disabilities. Furthermore, traumatic injuries occur at disproportionately higher rates in low- and middle-income countries, with approximately 90% of injuries and more than 90% of global deaths from injury occurring these countries. Injuries are increasing worldwide, crossing international boundaries and affecting a large number of people, in the same manner Human Immunodeficiency Virus did in the 1980's and COVID-19 is today. The tremendous global effort to tackle the COVID-19 and Human Immunodeficiency Virus pandemics has occurred whilst ignoring the comparable pandemic of injury. Without change and future engagement with policy makers and international donors this disparity is likely to continue.
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Nieuwoudt L, Rodseth RN, Marais LC. Fracture-related infections in HIV infected patients: A systematic review and meta-analysis. J Orthop 2020; 18:248-254. [PMID: 32071513 DOI: 10.1016/j.jor.2020.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 01/19/2020] [Indexed: 02/02/2023] Open
Abstract
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.
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Affiliation(s)
- Luan Nieuwoudt
- Tumour, Sepsis & Reconstruction Unit, Grey's Hospital, Pietermaritzburg, 3201, KwaZulu-Natal, South Africa
| | - Reitze N Rodseth
- Department Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa.,Jones, Bhagwan and Partners, Pietermaritzburg, South Africa
| | - Leonard Charles Marais
- Department Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
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The Viability of Percutaneous Bone-Anchored Hearing Systems in the HIV Population. Otol Neurotol 2019; 39:e1064-e1068. [PMID: 30247430 DOI: 10.1097/mao.0000000000002007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the viability of percutaneous bone-anchored hearing systems (BAHS), in terms of local soft tissue complications, in the HIV population. STUDY DESIGN Retrospective folder review. SETTING Two tertiary-level academic state hospitals in Cape Town, South Africa. PATIENTS Twenty patients, of which six (30%) were HIV-positive. All HIV-positive patients had CD4 counts greater than 200, and were on highly-active antiretroviral therapy (HAART). INTERVENTION Percutaneous BAHS implantation surgery was performed on all patients. MAIN OUTCOME MEASURE Comparisons were made between HIV-positive and HIV-negative patients in terms of incidence of local soft tissue complications post-implantation. RESULTS Soft tissue complications occurred in 50% of patients, and most were easily managed with topical treatment. No significant differences were found when comparing incidence of local soft tissue complications between HIV-positive and HIV-negative patients (p = 0.314). Similarly, surgical technique did not influence soft tissue complication incidence (p = 0.143). CONCLUSIONS No significant differences in incidence of local soft tissue complications after percutaneous BAHS implantation were found between HIV-positive and HIV-negative patients. In a resource-constrained country like South Africa, where cost and time management are vital, these results indicate that the use of percutaneous BAHS implantation is a viable option, even in HIV-positive patients.
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McQuillan TJ, Cai LZ, Corcoran-Schwartz I, Weiser TG, Forrester JD. Surgical Site Infections after Open Reduction Internal Fixation for Trauma in Low and Middle Human Development Index Countries: A Systematic Review. Surg Infect (Larchmt) 2018; 19:254-263. [DOI: 10.1089/sur.2017.273] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Lawrence Z. Cai
- Stanford University School of Medicine, Stanford, California
| | - Ian Corcoran-Schwartz
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Thomas G. Weiser
- Department of General Surgery, Stanford University, Stanford, California
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, Scotland
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Bryson DJ, Morris DLJ, Shivji FS, Rollins KR, Snape S, Ollivere BJ. Antibiotic prophylaxis in orthopaedic surgery: difficult decisions in an era of evolving antibiotic resistance. Bone Joint J 2017; 98-B:1014-9. [PMID: 27482011 DOI: 10.1302/0301-620x.98b8.37359] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 02/29/2016] [Indexed: 12/14/2022]
Abstract
Prophylactic antibiotics can decrease the risk of wound infection and have been routinely employed in orthopaedic surgery for decades. Despite their widespread use, questions still surround the selection of antibiotics for prophylaxis, timing and duration of administration. The health economic costs associated with wound infections are significant, and the judicious but appropriate use of antibiotics can reduce this risk. This review examines the evidence behind commonly debated topics in antibiotic prophylaxis and highlights the uses and advantages of some commonly used antibiotics. Cite this article: Bone Joint J 2016;98-B:1014-19.
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Affiliation(s)
- D J Bryson
- Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - D L J Morris
- King's Mill Hospital, Sutton-in-Ashfield, Nottinghamshire, NG17 4JL, UK
| | - F S Shivji
- Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - K R Rollins
- Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - S Snape
- Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Rd, Nottingham NG5 1PB, UK
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Fracture management in HIV positive individuals: a systematic review. INTERNATIONAL ORTHOPAEDICS 2016; 40:2429-2445. [PMID: 27655034 DOI: 10.1007/s00264-016-3285-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 08/25/2016] [Indexed: 12/18/2022]
Abstract
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.
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Haug L, Wazakili M, Young S, Van den Bergh G. Longstanding pain and social strain: patients' and health care providers' experiences with fracture management by skeletal traction; a qualitative study from Malawi. Disabil Rehabil 2016; 39:1714-1721. [PMID: 27440263 DOI: 10.1080/09638288.2016.1207109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM The aim of the study is to contribute to a more holistic evidence based on lower limb fracture management in low-income settings, by exploring the perspectives of those actually experiencing and administering skeletal traction in Malawi. METHODS The study took place at Queen Elizabeth Central Hospital in Blantyre and Kamuzu Central Hospital in Lilongwe, the two largest public hospitals of Malawi. Qualitative data were collected by participant observation, individual interviews with eight patients, two orthopedic surgeons, one physiotherapist, and two focus group discussions with multidisciplinary teams. RESULTS Patients experienced physical and psychological pain from the prolonged traction treatment in bed. Anxiety, indignity and emotional distress in the ward environment were commonly observed. Patients emphasized the negative impact on their families and the significant economic consequences due to prolonged hospitalization. Health care providers identified the major obstacles for quality treatment due to the lack of staff, equipment, specialized knowledge and skills. Rehabilitation services were nearly absent, thus little effort was made to maintain function and enhance recovery during and after long-term bed confinement. CONCLUSION The use of long-term skeletal traction has a devastating impact on the patients and families, and causes major frustrations to health workers involved with fracture management in a low-resource setting. Implications for Rehabilitation As stated by various health care providers, there is a need to improve trauma care, strengthen rehabilitation services and educate more rehabilitation staff so they can take up the different roles and functions required in treatment and rehabilitation after injuries and other debilitating conditions. In the current situation, sufficient pain relief for patients is required. This should go hand in hand with the empowerment of patients so as to fulfill their rights to quality health services. For health care providers, multidisciplinary teamwork, enhanced specialized education and skills, improved access to adequate equipment and developing standardized procedures appear essential in order to improve fracture management. With injuries representing a growing portion of the global burden of disease, and in the changing demographic panorama with aging populations in Africa and the world at large, injury prevention, trauma care- and rehabilitation need a stronger focus in public health globally.
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Affiliation(s)
- Lise Haug
- a Department of Occupational Therapy, Physiotherapy and Radiography , Bergen University College , Bergen , Norway
| | | | - Sven Young
- c Department of Surgery , Kamuzu Central Hospital , Lilongwe , Malawi.,d Department of Orthopaedic Surgery , Haukeland University Hospital , Bergen , Norway
| | - Graziella Van den Bergh
- a Department of Occupational Therapy, Physiotherapy and Radiography , Bergen University College , Bergen , Norway
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12
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Pretell-Mazzini J, Subhawong T, Hernandez VH, Campo R. HIV and Orthopaedics: Musculoskeletal Manifestations and Outcomes. J Bone Joint Surg Am 2016; 98:775-86. [PMID: 27147691 DOI: 10.2106/jbjs.15.00842] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤Advances in combined antiretroviral therapy (cART) in recent years have transformed HIV infection into a chronic disease when treatment is available, increasing a patient's life expectancy and the chances that orthopaedic surgeons will encounter such patients in their clinical practice.➤Musculoskeletal manifestations in patients with HIV infection are common and sometimes are the initial presentation of the disease. Knowledge about neoplasms and associated conditions affecting muscle, bones, and joints is essential for successful management.➤Since the advent of cART, total joint arthroplasty has been shown to be a safe procedure; however, perioperative infection is still a small risk in patients with uncontrolled viral loads or CD4 counts of <400 cells/mm(3).➤With regard to trauma surgery, the rates of early and late infection around implants, as well as union rates, are comparable with those in the HIV-negative population; however, there is an increased risk of pulmonary, renal, and infectious or septic complications in the polytrauma setting.➤Factors such as CD4 count, nutritional status, cART therapy, viral load count, and other comorbidities (hemophilia, infection among intravenous drug users, etc.) should be considered when treating these patients in order to optimize their clinical outcomes.
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Affiliation(s)
- Juan Pretell-Mazzini
- Departments of Orthopaedic Surgery (J.P.-M. and V.H.H.) and Radiology (T.S.), and Division of Infectious Diseases, Department of Internal Medicine (R.C.), University of Miami Miller School of Medicine, Miami, Florida
| | - Ty Subhawong
- Departments of Orthopaedic Surgery (J.P.-M. and V.H.H.) and Radiology (T.S.), and Division of Infectious Diseases, Department of Internal Medicine (R.C.), University of Miami Miller School of Medicine, Miami, Florida
| | - Victor H Hernandez
- Departments of Orthopaedic Surgery (J.P.-M. and V.H.H.) and Radiology (T.S.), and Division of Infectious Diseases, Department of Internal Medicine (R.C.), University of Miami Miller School of Medicine, Miami, Florida
| | - Rafael Campo
- Departments of Orthopaedic Surgery (J.P.-M. and V.H.H.) and Radiology (T.S.), and Division of Infectious Diseases, Department of Internal Medicine (R.C.), University of Miami Miller School of Medicine, Miami, Florida
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13
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Zhao CS, Li X, Zhang Q, Sun S, Zhao RG, Cai J. Early Outcomes of Primary Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Patients with Human Immunodeficiency Virus in China. Chin Med J (Engl) 2016; 128:2059-64. [PMID: 26228219 PMCID: PMC4717963 DOI: 10.4103/0366-6999.161364] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Qiang Zhang
- Department of Orthopedics, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
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14
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King JT, Perkal MF, Rosenthal RA, Gordon AJ, Crystal S, Rodriguez-Barradas MC, Butt AA, Gibert CL, Rimland D, Simberkoff MS, Justice AC. Thirty-day postoperative mortality among individuals with HIV infection receiving antiretroviral therapy and procedure-matched, uninfected comparators. JAMA Surg 2015; 150:343-51. [PMID: 25714794 DOI: 10.1001/jamasurg.2014.2257] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Antiretroviral therapy (ART) has converted human immunodeficiency virus (HIV) infection into a chronic condition, and patients now undergo a variety of surgical procedures, but current surgical outcomes are inadequately characterized. OBJECTIVE To compare 30-day postoperative mortality in patients with HIV infection receiving ART with the rates in uninfected individuals. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of nationwide electronic medical record data from the US Veterans Health Administration Healthcare System, October 1, 1996, to September 30, 2010. Common inpatient surgical procedures were grouped using the Healthcare Cost and Utilization Project Clinical Classification System to match HIV-infected and uninfected patients in a 1:2 ratio. Data on 1641 patients with HIV infection receiving combination ART who were undergoing inpatient surgery were compared with data on 3282 procedure-matched, uninfected comparators. Poisson regression models of 30-day postoperative mortality were adjusted for procedure year, age, Charlson Comorbidity Index score, hemoglobin level, albumin level, HIV infection, CD4 cell count, and HIV-1 RNA level. MAIN OUTCOMES AND MEASURES All-cause 30-day postoperative mortality. RESULTS The most common procedures in both groups were cholecystectomy (10.5%), hip arthroplasty (10.5%), spine surgery (9.8%), herniorrhaphy (7.4%), and coronary artery bypass grafting (7.0%). In patients with HIV infection, CD4 cell distributions were 80.0% with 200/μL or more, 16.3% with 50/μL to 199/μL, and 3.7% with less than 50/μL; 74.1% of patients with HIV infection had undetectable HIV-1 RNA. Human immunodeficiency virus infection was associated with higher 30-day postoperative mortality compared with the mortality in uninfected patients (3.4% [56 patients]) vs 1.6% [53]); incidence rate ratio [IRR], 2.11; 95% CI, 1.41-3.17; P < .001). CD4 cell count was inversely associated with mortality, but HIV-1 RNA provided no additional information. After adjustment, patients with HIV infection had increased mortality compared with uninfected patients at all CD4 cell count strata (≥500/μL: IRR, 1.92; 95% CI, 1.02-3.60; P = .04; 200-499/μL: IRR, 1.89; 95% CI, 1.20-2.98; P = .01; 50-199/μL: IRR, 2.66; 95% CI, 1.29-5.47; P = .01; and <50/μL: IRR, 6.21; 95% CI, 3.55-10.85; P < .001). Hypoalbuminemia (IRR, 4.35; 95% CI, 2.78-6.81; P < .001) and age in decades (IRR, 1.47; 95% CI, 1.23-1.76; P < .001) were also strongly associated with mortality. CONCLUSIONS AND RELEVANCE Current postoperative mortality rates among individuals with HIV infection who are receiving ART are low and are influenced as much by hypoalbuminemia and age as by CD4 cell status. Human immunodeficiency virus infection and CD4 cell count are only 2 of many factors associated with surgical outcomes that should be incorporated into surgical decision making.
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Affiliation(s)
- Joseph T King
- Section of Neurosurgery, Department of Surgery, Veterans Affairs (VA) Connecticut Healthcare System, West Haven2Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Melissa F Perkal
- Section of General Surgery, Department of Surgery, VA Connecticut Healthcare System, West Haven4Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Ronnie A Rosenthal
- Section of General Surgery, Department of Surgery, VA Connecticut Healthcare System, West Haven4Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Adam J Gordon
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania6Department of Medicine, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania7Division of Infectious Diseases, Department of Medicine, University of Pittsbur
| | - Stephen Crystal
- Center for Health Services Research on Pharmacotherapy, Chronic Disease Management, and Outcomes, Rutgers University, New Brunswick, New Jersey
| | - Maria C Rodriguez-Barradas
- Section of Infectious Diseases, Department of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas10Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Adeel A Butt
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania6Department of Medicine, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania7Division of Infectious Diseases, Department of Medicine, University of Pittsbur
| | - Cynthia L Gibert
- Section of Infectious Diseases, Medical Service, VA Medical Center, Washington, DC12Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - David Rimland
- Division of Infectious Diseases, Department of Medicine, Atlanta VA Medical Center, Atlanta, Georgia14Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Michael S Simberkoff
- Section of Infectious Diseases, Department of Medicine, VA New York Harbor Healthcare System, New York, New York16Section of Infectious Diseases, Department of Medicine, New York University School of Medicine, New York
| | - Amy C Justice
- Section of General Internal Medicine, Department of Medicine, VA Connecticut Healthcare System, West Haven18Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
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Kremers HM, Nwojo ME, Ransom JE, Wood-Wentz CM, Melton LJ, Huddleston PM. Trends in the epidemiology of osteomyelitis: a population-based study, 1969 to 2009. J Bone Joint Surg Am 2015; 97:837-45. [PMID: 25995495 PMCID: PMC4642868 DOI: 10.2106/jbjs.n.01350] [Citation(s) in RCA: 243] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The epidemiology of osteomyelitis in the United States is largely unknown. The purpose of this study was to determine long-term secular trends in the incidence of osteomyelitis in a population-based setting. METHODS The study population comprised 760 incident cases of osteomyelitis first diagnosed between January 1, 1969, and December 31, 2009, among residents of Olmsted County, Minnesota. The complete medical records for each potential subject were reviewed to confirm the osteomyelitis diagnosis and to extract details on anatomical sites, infecting organisms, etiological risk factors, and outcomes. RESULTS The overall age and sex-adjusted annual incidence of osteomyelitis was 21.8 cases per 100,000 person-years. The annual incidence was higher for men than for women and increased with age (p < 0.001). Rates increased with the calendar year (p < 0.001) from 11.4 cases per 100,000 person-years in the period from 1969 to 1979 to 24.4 per 100,000 person-years in the period from 2000 to 2009. The incidence remained relatively stable among children and young adults but almost tripled among individuals older than sixty years; this was partly driven by a significant increase in diabetes-related osteomyelitis from 2.3 cases per 100,000 person-years in the period from 1969 to 1979 to 7.6 cases per 100,000 person-years in the period from 2000 to 2009 (p < 0.001). Forty-four percent of cases involved Staphylococcus aureus infections. CONCLUSIONS The reasons for the increase in osteomyelitis between 1969 and 2009 are unclear but could comprise a variety of factors, including changes in diagnosing patterns or increases in the prevalence of risk factors (e.g., diabetes) in this population.
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Affiliation(s)
- Hilal Maradit Kremers
- Departments of Health Sciences Research (H.M.K., J.E.R., C.M.W.-W., and L.J.M.) and Orthopedic Surgery (P.M.H.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for H.M. Kremers:
| | - Macaulay E. Nwojo
- Dignity Health St. Joseph’s Hospital and Medical Center, 300 West Thomas Road, Phoenix, AZ 85013
| | - Jeanine E. Ransom
- Departments of Health Sciences Research (H.M.K., J.E.R., C.M.W.-W., and L.J.M.) and Orthopedic Surgery (P.M.H.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for H.M. Kremers:
| | - Christina M. Wood-Wentz
- Departments of Health Sciences Research (H.M.K., J.E.R., C.M.W.-W., and L.J.M.) and Orthopedic Surgery (P.M.H.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for H.M. Kremers:
| | - L. Joseph Melton
- Departments of Health Sciences Research (H.M.K., J.E.R., C.M.W.-W., and L.J.M.) and Orthopedic Surgery (P.M.H.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for H.M. Kremers:
| | - Paul M. Huddleston
- Departments of Health Sciences Research (H.M.K., J.E.R., C.M.W.-W., and L.J.M.) and Orthopedic Surgery (P.M.H.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for H.M. Kremers:
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Phaff M, Aird J, Rollinson PD. Delayed implants sepsis in HIV-positive patients following open fractures treated with orthopaedic implants. Injury 2015; 46:590-4. [PMID: 25650266 DOI: 10.1016/j.injury.2015.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 01/01/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND There has been concern that HIV-positive patients may be more susceptible to delayed infection (>1 month) after treatment of open fractures with orthopaedic implants. To date, the longest published follow-up for such patients is 6 months. AIM Long-term follow-up to identify rates of delayed implant sepsis in open fractures treated with internal fixation, in HIV positive patients and controls. METHODS Prospective observational study. Between March 2011 and April 2012, we attempted to contact all patients who were enrolled into a study looking at outcomes of open fractures treated with internal fixation between May 2008 and March 2009. Telephone questionnaires were used to screen for implant sepsis, and patients received clinical assessments at our research clinic. RESULTS Of 101 patients with in situ implants, we were able to follow 51 patients. Of the initial 33 HIV-positive patients, 13 were reassessed as part of this study. Only 1 of 13 HIV-positive patients developed delayed implant sepsis following a grade 3B open tibia fracture. Two of 23 HIV-negative patients developed delayed implant sepsis. CONCLUSION With an average follow-up period of 39 months (range=34-43 months), this is the longest follow-up period to evaluate HIV-positive patients with open fractures who received orthopaedic implants. Despite its limitations of poor follow up, it provides the strongest available evidence that in our setting HIV positive patients are not at higher risk of delayed sepsis, and we would not suggest routine removal of metal work in these patients.
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Affiliation(s)
- Martijn Phaff
- Department of Orthopedics, Inkosi Albert Luthuli Central Hospital, Durban, South Africa.
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17
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Graham SM, Bates J, Mkandawire N, Harrison WJ. Late implant sepsis after fracture surgery in HIV positive patients. Injury 2015; 46:580-4. [PMID: 25601086 DOI: 10.1016/j.injury.2014.12.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/11/2014] [Indexed: 02/02/2023]
Abstract
A prospective cohort study was undertaken to assess the incidence of late-implant sepsis after internal fixation in HIV-positive patients. A total of 91 HIV-positive patients (67 males and 24 females) who underwent 103 procedures (111 implants) were followed up for a mean period of 27 months (range 12-66 months). No occurrences of late implant sepsis were found in 100 implants (94 procedures) in 82 patients at 27 months' follow-up (range 12-66 months). Nine patients (9 procedures, 9 implants) developed early infections within 6 weeks and were treated with antibiotics (6 patients), amputation (1 patient) or removal of metal work (2 patients). There was no evidence of subsequent late implant sepsis in any of these patients, at a mean follow-up of 25 months (range 12-52 months). This study demonstrates that it is safe to perform internal fixation in HIV-positive patients, with no observed increase risk of late implant sepsis. There is no indication to remove implants after fracture union, other than for the general clinical indications that may lead to removal of metal work in any patient.
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Affiliation(s)
- Simon Matthew Graham
- The Countess of Chester Hospital, Health Park, Chester, Cheshire, United Kingdom.
| | - Jes Bates
- Beit CURE International Hospital, Blantyre, Malawi; The Department of Surgery, College of Medicine University of Malawi, Malawi
| | - Nyengo Mkandawire
- Beit CURE International Hospital, Blantyre, Malawi; The Department of Surgery, College of Medicine University of Malawi, Malawi; School of Medicine, Faculty of Health Sciences, Flinders University, Australia
| | - William J Harrison
- The Countess of Chester Hospital, Health Park, Chester, Cheshire, United Kingdom; Beit CURE International Hospital, Blantyre, Malawi
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18
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Hao J, Herbert B, Quispe JC, Cuellar DO, Chadayammuri V, Kim JW, Young H, Hake ME, Hammerberg ME, Hak DJ, Mauffrey C. An observational case series of HIV-positive patients treated with open reduction internal fixation for a closed lower extremity fracture. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:815-9. [DOI: 10.1007/s00590-015-1595-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 12/20/2014] [Indexed: 10/24/2022]
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Howard NE, Phaff M, Aird J, Wicks L, Rollinson P. Does human immunodeficiency virus status affect early wound healing in open surgically stabilised tibial fractures?: A prospective study. Bone Joint J 2014; 95-B:1703-7. [PMID: 24293603 DOI: 10.1302/0301-620x.95b12.32083] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- N E Howard
- Mersey Deanery Orthopaedic Training Programme, Orthopaedic Department, Royal Liverpool University Hospital, Prescot Street, L7 8XP Liverpool, UK
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20
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Randelli F, Pulici L, Favilla S, Maglione D, Zaolino C, Carminati S, Pace F, Randelli P. Complications related to fracture treatment in HIV patients: a case report. Injury 2014; 45:379-82. [PMID: 24119651 DOI: 10.1016/j.injury.2013.09.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2013] [Indexed: 02/02/2023]
Abstract
We present the case report of a 40-year-old woman who was HIV-positive in Highly Active Anti-Retroviral Therapy (HAART) and affected by femural pertrochanteric fracture, which was treated by endomedullary nailing. Two years after the surgical operation, the woman developed an aseptic symptomatic osteolysis around the implant. Hardware removal was resolutive. Aseptic and septic hardware mobilization, hardware removal, and implant decision in HIV patients with pertrochanteric fractures is discussed. The authors suggest close follow-up and prompt hardware removal, as soon as X-rays demonstrate healing signs, in HIV patients with fracture fixation, if general condition allows.
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Affiliation(s)
- F Randelli
- I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy.
| | - L Pulici
- I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - S Favilla
- I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - D Maglione
- I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - C Zaolino
- I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - S Carminati
- I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - F Pace
- I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - P Randelli
- I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
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21
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Young S, Banza LN, Hallan G, Beniyasi F, Manda KG, Munthali BS, Dybvik E, Engesæter LB, Havelin LI. Complications after intramedullary nailing of femoral fractures in a low-income country. Acta Orthop 2013; 84:460-7. [PMID: 24171678 PMCID: PMC3822130 DOI: 10.3109/17453674.2013.850014] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 08/31/2013] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Some surgeons believe that internal fixation of fractures carries too high a risk of infection in low-income countries (LICs) to merit its use there. However, there have been too few studies from LICs with sufficient follow-up to support this belief. We first wanted to determine whether complete follow-up could be achieved in an LIC, and secondly, we wanted to find the true microbial infection rate at our hospital and to examine the influence of HIV infection and lack of follow-up on outcomes. PATIENTS AND METHODS 137 patients with 141 femoral fractures that were treated with intramedullary (IM) nailing were included. We compared outcomes in patients who returned for scheduled follow-up and patients who did not return but who could be contacted by phone or visited in their home village. RESULTS 79 patients returned for follow-up as scheduled; 29 of the remaining patients were reached by phone or outreach visits, giving a total follow-up rate of 79%. 7 patients (5%) had a deep postoperative infection. All of them returned for scheduled follow-up. There were no infections in patients who did not return for follow-up, as compared to 8 of 83 nails in the group that did return as scheduled (p = 0.1). 2 deaths occurred in HIV-positive patients (2/23), while no HIV-negative patients (0/105) died less than 30 days after surgery (p = 0.03). INTERPRETATION We found an acceptable infection rate. The risk of infection should not be used as an argument against IM nailing of femoral fractures in LICs. Many patients in Malawi did not return for follow-up because they had no complaints concerning the fracture. There was an increased postoperative mortality rate in HIV-positive patients.
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Affiliation(s)
- Sven Young
- Department of Orthopaedic Surgery , Haukeland University Hospital , Bergen
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22
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Fracture union following internal fixation in the HIV population. Injury 2013; 44:830-3. [PMID: 23267724 DOI: 10.1016/j.injury.2012.11.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 10/23/2012] [Accepted: 11/25/2012] [Indexed: 02/02/2023]
Abstract
INTRODUCTION HIV is thought to be associated with increased rates of fracture non-union. We report on a prospective cohort of 96 HIV positive patients with 107 fractures that required internal fixation. The CD4 count was measured and patients were reviewed until eventual clinical or radiological union or non-union was established. RESULTS Four percent of fractures (4 out of 100) failed to unite. Three patients required one further procedure to induce union, and two developed avascular necrosis. The CD4 count was not related to fracture union. CONCLUSION Contrary to previous assumptions, this study suggests that HIV infection does not increase rates of non-union in surgically managed fractures.
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