Open fractures of the tibia in HIV positive patients: a prospective controlled single-blind study

Harrison, William J.; Lewis, Charles P.; Lavy, Christopher

doi:10.1016/j.injury.2004.01.005

Cited by 52 publications

(42 citation statements)

References 10 publications

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“…Court Brown reported infection rates ranging from 1.8% to 12.5%. 20 Yokoyama et al, Agrawal et al and Joshi et al reported deep infection rates of 6.1%, 10% and 10.1% respectively. [33][34][35] The results in this study show a superficial infection rate of 10.8% and a deep infection of 6.8%, and are comparable to international literature.…”

Section: Discussionmentioning

confidence: 94%

“…Harrison et al attributed HIV as possibly the cause for sepsis and delayed union in his series of 27 patients and advocated the use of an external fixator over an intramedullary device. 20 In direct contrast, Aird et al reported that HIV-positive patients with open tibial fractures can be managed with both internal and external fixation methods but cautioned against a certain subgroup in grade 1 injuries with advanced HIV infection. 40 Howard et al concluded that HIVpositive patients with a CD4 count >350 cells/mm are not at risk of early wound sepsis when compared to HIV-negative patients.…”

Section: Discussionmentioning

confidence: 99%

“…17,18 The fear of osteomyelitis has previously precluded any form of internal fixation especially in the immune-compromised host and delays in operative management greater than six hours. 19,20 Reamed nails offer a biological and mechanical advantage, however injurious to the endosteal vasculature with subsequent theoretical increase in infection and non-union. 21 With the improvement in antibiotic use and surgical technique, the use of intramedullary nails has evolved from low energy open Gustilo grade 1 and grade 2 fractures to more severe Gustilo grade 3 injuries, with excellent long-term results.…”

Section: Introductionmentioning

confidence: 99%

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Outcomes of intramedullary nailing for open fractures of the tibial shaft

Seron¹,

Rasool

2018

SA orthop. j.

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Aim: To establish superficial and deep infection rates and time to union of open tibial shaft fractures treated with primary debridement and locked intramedullary nails. Materials and methods:The clinical records and radiographs were retrospectively reviewed of 74 Gustilo-Anderson grades 1 to 3A open tibial shaft fractures that were treated by initial debridement and intramedullary nail fixation over a two-year period. Sixty-three men and nine women with a mean age of 33 years (range 16-67) were followed up for a mean period of 18 months (range 7-32).Results: Sixteen patients (22%) sustained grade 1 injuries, 38 (51%) grade 2, and 20 (27%) had grade 3A injuries. Thirteen patients (18.1%) were HIV positive. The mean time to surgery was 28 hours (range 8-112). The overall infection rate was 17.6%. Superficial infection developed in 10.8% and deep infection occurred in 6.8%. There was no association between time to surgery and infection rate (p=0.878). There was no association between HIV status and infection (p=0.471). There was no association between type of closure and sepsis (p=0.410). The mean time to union was 17 weeks (range 12-50). Five patients (6.9%) had delayed union and one patient failed to unite without undergoing secondary procedures. Conclusion:The management of Gustilo-Anderson grade 1 to 3A open tibial shaft fractures with primary debridement and locked intramedullary nailing shows good short-term results with low infection and non-union rates despite delay in surgical management or HIV infection. Level of evidence: Level 4Key words: open tibial fractures, intramedullary nails, infection, union

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Section: Discussionmentioning

confidence: 94%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Outcomes of intramedullary nailing for open fractures of the tibial shaft

Seron¹,

Rasool

2018

SA orthop. j.

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“…Pro [32] NSAID use at admission Pro [13,27] Con [17,35] NSAID use at discharge Pro [13,27] Con [17,35] Opioid use at admission Pro [12] Opioid use at discharge Pro [12] Human immunodeficiency virus Pro [24] Con [20] Hepatitis C None Diabetes Pro [13,21,27] ASA score Pro [16] Smoking status Pro [13,21,31,36] Con [29,35] Alcohol use Pro [10,13,21] AO classification Pro [30] Con [2,22] ISS score Pro [30] TRISS score Pro [30] ICU days None * Pro articles support a correlation between nonunion and the variable; Con articles show that the variable has no correlation with nonunion; GSW = gunshot wound; NSAID = nonsteroidal anti-inflammatory drug; ASA = American Society of Anesthesiologists; AO = Arbeitsgemeinschaft für Osteosynthesefragen; ISS = Injury Severity Score; TRISS = Trauma and Injury Severity Score; ICU = intensive care unit.…”

Section: Compartment Syndromementioning

confidence: 99%

Will My Tibial Fracture Heal? Predicting Nonunion at the Time of Definitive Fixation Based on Commonly Available Variables

O’Halloran

Coale

Costales

et al. 2016

Clinical Orthopaedics &Amp; Related Research

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Background Accurate prediction of tibial nonunions has eluded researchers. Reliably predicting tibial nonunions at the time of fixation could change management strategies and stimulate further research. Questions/purposes We asked (1) whether data from medical records, fracture characteristics, and radiographs obtained at the time of fixation would identify features predictive of tibial fracture nonunion; and (2) whether this information could be used to create a model to assess the chance of nonunion at the time of intramedullary (IM) nail fixation of the tibia. Methods We retrospectively reviewed all tibial shaft fractures treated at our center from 2007 to 2014. We conducted a literature review and collected data on 35 factors theorized to contribute to delayed bone healing. Patients were followed to fracture healing or surgery for nonunion. Patients with planned prophylactic nonunion surgery were excluded because their nonunions were anticipated and our focus was on unanticipated nonunions. Our cohort consisted of 382 patients treated with IM nails for tibial shaft fractures (nonunion, 56; healed, 326). Bivariate and multivariate regression techniques and stepwise modeling approaches examined the relationship between variables available at definitive fixation. Factors were included in our model if they were identified as having a modest to large effect size (odds ratio [ 2) at the p \ 0.05 level. Results A multiple variable logistic regression model was developed, including seven factors (p \ 0.05; odds ratio [ 2.0). With these factors, we created the Nonunion Risk Determination (NURD) score. The NURD score assigns 5 points for flaps, 4 points for compartment syndrome, 3 points for chronic condition(s), 2 points for open fractures, 1 point for male gender, and 1 point per grade of American Society of Anesthesiologists Physical Status and percent cortical contact. One point each is subtracted for spiral fractures and for low-energy injuries, which were found to be predictive of union. A NURD score of 0 to 5 had a 2% chance of nonunion; 6 to 8, 22%; 9 to 11, 42%; and[12, 61%. Conclusions The proposed nonunion prediction model (NURDS) seems to have potential to allow clinicians to better determine which patients have a higher risk of nonunion. Future work should be directed at prospectively validating and enhancing this model. Level of Evidence Level III, diagnostic study.

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“…Treatment of open tibia fractures is often hampered by delays and inadequate resources and expertise. We have undertaken three studies relevant to this topic: a prospective study of open tibia fractures comparing HIV positive and negative patients 2 , a prospective study of internal fracture fixation including cases in open fractures comparing wound infection for HIV positive and negative patients 3 , and a prospective study of pin track sepsis comparing HIV positive and negative patients 4 . This report aims to summarise the relevant data from these studies and draw some conclusions regarding current practice and remaining questions.…”

Section: Introductionmentioning

confidence: 99%

Open tibia fractures in HIV positive patients

Harrison¹

2010

Mal. Med. J

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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.

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Open fractures of the tibia in HIV positive patients: a prospective controlled single-blind study

Cited by 52 publications

References 10 publications

Outcomes of intramedullary nailing for open fractures of the tibial shaft

Outcomes of intramedullary nailing for open fractures of the tibial shaft

Will My Tibial Fracture Heal? Predicting Nonunion at the Time of Definitive Fixation Based on Commonly Available Variables

Open tibia fractures in HIV positive patients

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