These days when HIV (Human Immunodeficiency Virus) has become a largely manageable problem in the developed world it is sometimes hard to remember that there are still areas where a diagnosis of HIV will lead to death.
In South Africa, for example, a 2010 UNAIDS report found that in 2009 an estimated 310,000 South Africans died of AIDS. The same report found that an estimated 5.6 million people were living with HIV and AIDS in the country, more than anywhere else in the world.1 Yet it is important to note that in addition to those who have died from AIDS related illnesses there will also have been HIV positive patients who died not of AIDS but because of the high risk of infective complications following injury.
This is particularly true where open fractures are concerned. Great advances have been made in the management of open fractures since Sir Percival Pott sustained an open facture of his tibia on the Old Kent Road and arranged for his immediate transport to Watling Street preventing movement of his limb during his journey thus promoting the external splint. The effective use of wound excision and removal of dead tissue and inert material from the wound have been demonstrated. The results from using intramedullary nailing in all Gustillo grades of open fracture have been shown to be good in otherwise healthy patients2 and combined with adequate antibiotic therapy and effective wound cover using muscle flaps, real advances have been established in treating these difficult fractures.
Yet in some parts of the world open fractures remain notoriously difficult to treat and can still lead to amputation and death. The presence of HIV, which may induce immuno-suppression in a patient, is therefore a very high risk factor in treating patients who have open fractures.
When you then consider the difficulties in many parts of Africa such as a delay in reaching hospital or in treating patients who sustain open limb fractures it becomes clear that there is a real problem with the management of open fractures in this region.
Several authors with experience of working in Africa have reported high infection rates when treating open fractures. Jellis3 reported a 72% infection rate and a nonunion rate of 28% in patients who were HIV positive and had open fractures. Harrison, Lewis and Lavy4 reported a 42% rate of infection in patients with similar problems. This, therefore, raises the question as to whether internal fixation can be used in patients who sustain open fractures and are also HIV positive.
So what, if anything, can be done? This important paper by Aird et al5 sets out to re-examine the question of the effect of HIV on early wound healing in patients who have sustained open fractures and are treated by internal or external fixation. In doing so it advocates reversing the current perceived wisdom that internal or external fixation should not be practised in patients who have open fractures and are HIV positive.
In order to assess whether the authors are correct to come to this conclusion it is necessary to consider their study in greater depth.
The paper’s authors live in an area of South Africa with a high incidence of trauma, which is also one of the highest areas for HIV infection in the world.
They report a prospective observational study of 133 patients who underwent external or internal fixation for open fractures over a nine month a period between May 2008 and March 2009. The most commonly injured bone was the tibia. The patients were investigated for HIV and the wounds graded using the ASEPSIS scoring system.6 Of the patients seen, 33 were HIV positive, 86 were negative. The remaining 16 had an unknown HIV status.
Overall, the paper’s results show that the authors were unable to demonstrate that there was a higher rate of infection in patients who had internal or external fixation of their fractures in the presence of HIV compared with a group of patients treated at the same time who were did not have HIV. Therefore the authors conclude that internal or external fixation is justified in patients with open fractures even when they are HIV positive.
The CD4 count was also measured and they found that 58% of the HIV patients had a CD4 count of less than 350 cells/L, although none had a count below 100 cells/L. The report adds that those patients with a CD4 of less than 350 cells/L had an apparently higher incidence of wound infection than the unmatched controls.
The time to surgery was also of interest. Those patients with Gustillo Grade 1 fractures suffered a considerable delay in time before surgery, with a mean of 3.5 days, compared with for example Gustillo Grade III a and b, in which the wait for surgery was less than one day. They found that in the Gustillo I patients those who were HIV positive with a CD4 count of less than 350 cells/L showed an increased risk of wound sepsis. Hence they concluded that they needed to review their policy for treating these patients and that Gustillo grade I open fractures need to be treated early, in common with their practise for more severe grades of open fractures.
Crucially, therefore, the paper argues that a delay in treatment is associated with a higher risk of infection. Their findings illustrate that all fractures, irrespective of which grade they have been given, need to be treated effectively by wound debridement very early in order to prevent infection. They additionally question the value of using the Gustillo grading system7 as an index of urgency for treatment, arguing that the problem is in fact the actual insult of an open fracture on the patient as a whole and that treatment principles should be exactly the same irrespective of degree of the grading system. This includes time to surgery.
The fact that patients with low CD4 counts have a higher rate of infection emphasises the value of obtaining a CD4 count early in the patient’s management. It is arguable therefore that patients with low CD counts should perhaps have prolonged antibiotic therapy combined with immediate surgery.
It is also worth noting that the recent introduction of an effective AIDS programme in South Africa and the use of retroviral therapy such as HAART (Highly Active Anti-Retroviral Therapy) should raise the CD4 count in these patients who are most at risk from infection and, as the overall health of community improves along with the resolution of associated illnesses such as TB, these issues will become less important.
That said the paper is not without flaws. Most notably, as the authors acknowledge, they have not addressed the issue of late infection and are only looking at the early period that is within the first three months of the open fracture. The unanswered question is what is the real incidence of late infection in those patients who undergo internal or external fixation following open fractures who are HIV positive. It is quite possible that infection can occur later after the arbitrary three month period leading to chronic osteomyelitis as was reported by Jellis.
It is therefore important to undertake further research into whether late infection is a problem in order to assess the long-term implications of internal or external fixation in open fractures in HIV positive patients.
These are, however, minor criticisms of a seminal paper, which shows us a clear way forward and demonstrates that it is possible to treat HIV patients with open fractures without the disastrous results of the past. This in turn means that it should be increasingly possible for orthopaedic surgeons in Africa to follow similar lines of treatment to those laid out in the paper, that is early debridement of the wound and external or internal fixation of the fracture, irrespective of HIV status.
1. http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountries/southafrica_2010_country_progress_report_en.pdf p 10. (Or Editors Country Progress Report on the Declaration of Commitment on HIV/AIDS 2010 Report page 10).
2. Court- Brown CM, McQueen MM, Quaba AA, Christie J. Locked intramedullary nailing of open tibial fractures. J Bone Joint Surg [Br] 1991;73-B:959- 64.
3. Jellis JE. Orthopaedic surgery and HIV disease in Africa. Int Orthop 1996;20:253-6.
4. Harrison WJ, Lewis CP, Lavy CB. Wound healing after implant surgery in HIV-positive patients J Bone Joint Surg [Br] 2002;84-B:802-6.
5. Aird J, Noor S, Lavy C, Rollinson P. The effect of HIV on early wound healing in open fractures treated with internal and external fixation. J Bone Joint Surg [Br] 2011;93-B:678-83.
6. Wilson AP, Treasure T, Sturridge MF, Gruneberg RN. A scoring method (ASEPSIS) for post-operative wound infections for use in clinical trials of antibiotic prophylaxis. Lancet 1986;1:311-13.
7. Gustillo RB. Classification of Open Fractures. In: Ramon Ed, Gustillo RB (eds). Management of open fractures and their complications, WB Saunders, 1982.
Emeritus Professor Orthopaedic Surgery
Imperial College London