Vol 2 | Issue 2 | May - Aug 2014 | page 42-44 | Gavhale S V,Gawhale S K,Gavai P V, Dash K K, Yeragi B S

Author: Piyush V Gavai[1], Sangeet K Gawhale[2], Kumar Kaushik Dash[1], Bhakti S Yeragi[3]

[1]Department of Orthopedics, St. George Hospital, Shahid Bhagat Singh Road, Fort, Mumbai India.
[2]Sir JJ Group of Hospitals & GMC, Mumbai-India
[3]Department of Radiology, BYL Nair Hospital, Dr. A. L. Nair Road, Mumbai India.

Institute at which research was conducted: Dept. of Orthopaedics, Grant Medical College,Sir JJ Group of Hospitals,Byculla – 8.
University Affiliation of Thesis: Mumbai University.
Year of Acceptance: 2004

Address of Correspondence
Dr. Piyush V Gavai1
Department of Orthopedics, St. George Hospital, Shahid Bhagat Singh Road, Fort, Mumbai - 400001, India.
Email: dr_piyushgavai@yahoo.com

Abstract

Backgrounds: Acquired Immunodeficiency Syndrome caused by the Human Immunodeficiency Virus (HIV) is today one of the most common cause of secondary immunodeficiency. Fracture and soft tissue healing rates and risk of postoperative infections may differ in HIV infected patients.
Materials and Methods: A retrospective comparative study was conducted with of 40 randomly chosen cases of HIV infected patients and a control group of 40 patients.
Results: Thirty-one (77.5 %) patients presented with trauma, seventeen (42.5 %) due to motor vehicle accident, 13 (32.5 %) cases secondary to fall and one (2.5%) patient due to firearm injury. The average fracture healing time in closed fractures treated conservatively was found to be normal / comparable to healthy individuals in this study according to radiological and clinical parameters. The wound healing time and rate of infection in HIV infected individuals was comparable to normal individuals. For patients not in ARC, the post-operative infection rates are comparable with those for non-HIV patient population.
Conclusions: Fracture healing and wound healing rates doesn't differ significantly in HIV patients. However, the surgeon must be aware of the risk of late-onset hematogenous infections in HIV patients with ARC.
Keywords: HIV, infection, wound healing, fracture healing.
Thesis Question: 1. Is healing of wounds and fractures different between HIV infected individuals and normal counterparts?
2. What is the incidence of infection in these treated HIV infected patients?
Thesis Answer: 1. Wound healing and fracture healing in HIV infected individuals was comparable to healthy individuals.
2. Rate of infection in HIV positive Stage 2 was comparable to normal individuals. But patients in ARC (AIDS Related Complex) tend to develop late-onset implant related                                                    hematogenous infections.

Introduction

Acquired Immunodeficiency Syndrome caused by the Human Immunodeficiency Virus (HIV) is today one of the most common cause of secondary immunodeficiency. The AIDS pandemic is fast spreading across the globe. In India, 40,00,000 people have AIDS / HIV with a prevalence of 0.8 %33. AIDS is the end result of a progressively decreased immunological competence caused by HIV. The Human immunodeficiency virus damages and progressively destroys the immune system by interacting with the CD4 subset of helper T- cells and using them for replication. This results in an immunocompromised state in an individual infected with HIV and renders him susceptible to a variety of infections and diseases. It is highly likely that like any other illness of chronic nature, HIV infection may affect or actually retard the healing process necessary for convalescence. Fracture and soft tissue hjhjhnealing rates may be expected to suffer in HIV infected patients, more so in those with signs of AIDS-related complex. Owing to its immunosuppressive nature, the possibility or likelihood of postoperative infections should logically increase.

Aims and Objectives

• To study the healing of soft tissue injuries / open wounds in orthopedic patients infected with HIV.
• To study the rate of fracture healing in HIV infected patients.
• To study the incidence of infections in these treated HIV positive patients:
  1.In the immediate post-op period.
  2.In the follow up period.

Methods

A retrospective study was conducted at our institute in order to assess the response of HIV infected patients, treated for orthopedic conditions including trauma and other conditions. A total of 40 randomly chosen cases of HIV infected patients and a control group of 40 randomly chosen cases of non-HIV infected patients admitted in the orthopedics wards were selected for this study.
Patients were clinically assessed for any symptoms and signs of AIDS Related Complex (ARC) to determine the stage of the HIV infection by the Center For Disease Control (CDC) system of USA. Patients were examined on the second and tenth postoperative day to assess the wound healing and to rule out infection. The postoperative follow up of these patients was mainly in the form of clinical examination and X Rays with routine hemograms. The absolute lymphocyte count was calculated as a prognostic factor for fracture healing.

Results

The present study included 40 cases of HIV infected individuals compared with a study of 40 randomly chosen non- HIV infected patients. Thirty-one (77.5 %) patients presented with trauma, seventeen (42.5 %) due to motor vehicle accident, 13 (32.5 %) cases secondary to fall and one (2.5%) patient due to firearm injury. The average fracture healing time in these patients with closed fractures treated conservatively in casts or in traction was comparable to the study group. Eighteen (45%) trauma cases and eight (2.5%) cold cases were taken up for elective surgery strictly following the WHO guidelines for surgical precautions.68% trauma and 69% cases in the control group were taken up for surgery. Operative intervention in the symptomatic HIV infected individuals did not accelerate the rate of development of AIDS in any of the cases.

Conclusion

1. The average fracture healing time in closed fractures treated conservatively was found to be normal / comparable to healthy individuals in this study according to radiological and clinical parameters. This finding is consistent with the literature review.
2. In open fractures the rate of wound infection was higher (71.4 %) in seronegative individuals.
3. For patients not in ARC, the post-operative infection rates are comparable with those for non-HIV patient population. Patients who are in ARC tend to develop late-onset implant related hematogenous infection, which is probably similar to the mechanism of opportunistic infection.
4. The wound healing time and rate of infection in HIV + ve individuals in Stage 2 of CDC classification is comparable to normal individuals.

Clinical Message

Fracture healing and wound healing rates doesn't differ significantly in HIV patients. However, the surgeon must be aware of the risk of late-onset hematogenous infections in HIV patients with ARC.

Keywords

HIV, infection, wound healing, fracture healing.

Bibliography

1. Jellis J E. Orthopedic infection associatd with HIV Surgery 1994 12: 8 175-177.
2. Jellis J E. Orthopedic surgery and HIV in Africa Int . Orthop. 1996 ; 20( 4) :253-256.
3. Jellis J E The influence of HIV on Orthopedic practise JBJS (Br)1992 South African Orthopedic Association ;74 B Suppl 2 : 202.
4. Lemaire Rogers ; Masson Jean-Bernard : Risk of transmission of blood borne viral infection in orthopedic trauma JBJS (Br) 2000 Apr 82(3)313-323.
5. J J Behrans Prevelance of seropositivity for HIV patients who have severe trauma .JBJS 1992 ;74 ,64 641-645.
6. Lehmann Christopher Infection after Total Joint Arthroplasty in patients with HIV or intravenous drug abuse AAOS 1999 Poster Board No. 308.
7. AAOS 1996 Annual meeting – Scientific Program Relative rate of perioperative surgical infections in asymptomaic HIV positive Orthopedic patients.
8. Luck J V Jr, Instructional course lecture Orthopedic surgery on HIV positive patients –complications and outcomes 1994 ; 43: 543-549.
9. Norain John N TKR in hemophilic arthropathy JBJS 2002 ; 84 : 1138-1141.
10. Ragni M V The effect of antiviral therapy on the natural history of HIV infection. J of AIDS 1992 ;5:120-126.
11. Palement Postoperative infection in asymptomatic HIV positive patients J Trauma 1994 ;37:545-550.
12. Edelsiten HIV positive hemophilics and implant surgery JBJS 1992 Vol 74 ( Br) Supp 2 : 196.
13. Carl A , Sodersstorm HIV infection rates in a trauma center treating predominantly rural blunt trauma victims J Trauma 1989; 29 : 1526-1530.
14. Frochle Prevelance of HIV in trauma emergency room ArchivesOrtho.Trauma Surgery 1996 ; 115:337-338.
15. Hernigou HIV virus and orthopedic surgery Rev. Chir. Orthop. 1993 ;79:5-12.
16. Edward P Sloan Human Immunodefiency Virus and Hepatitis B virusseroprevelance in an urban trauma population The Journal of Trauma :Injury, Infection and Critical Care 1995 ;38 : 736-741.
17. Ellis S Caplan Seroprevelance of Human Immunodefiency Virus and Hepatitis B virus,Hepatitis C virus , and Rapid Plasma Reagin in a trauma population The Journal of Trauma :Injury, Infection and Critical Care 1995;39:533-538.
18. Palement Guy D Postoperative infections in asymtomatic HIV positive orthopedic patients The Journal of Trauma 1994 ; 37: 545-550.
19. Palement Guy D . Relative rate of perioperative surgical infections in asymptomatic HIV positive orthopedic patients AAOS 1994 Paper No. 520.
20. Mineriro J The risk of seroconversion in surgeons of the Hepatitis B,Hepatitis C and HIV in a specific surgical population Acta Med Port1997 Jun – Jul ; 10 (6-7) : 455-461.
21. Gakuu L N Postoperative pyrexia in orthopedic unit East Afr Med J 1997 Aug ;74(8) :530-532.
22. Sanchez L P Seroprevelance of blood borne transmissible diseases in trauma orthopedic surgical patients P R Health Sci J 1998 Jun ; 17(2) :113-116.
23. Haseltine W A Molecular biology of HIV type . FASEBJ 1991 ;5:2349-2360.
24. Fauci A S The HIV infectivity and mechanisms of pathogenesis. Science 1991; 239:617-622.
25. Fauci A S Immunopathogenic mechanisms in HIV infection . Ann Intern Med 1991; 114:678-693.
26. Volberding P A ; Kochs M A et al. Zidovudine in asymptomatic HIV infection a controlled trial in persons with fewer than 500 CD 4 positive cells /mm3. New Eng J Med 1990; 322:941-949.
27. Graham N H M , Parle L P et al Effect of Zidovudine and pneumocystis carini pneumonia prophylaxis on progression of HIV –1 infection to AIDS . Lancet 1991;338:265-269.
28. Lemp G F , Neal D Survival trends in patients with AIDS JAMA 1990;263: 402-402.
29. Tindall B, Cooper D A Primary HIV infection : Host responses and interventional strategies AIDS 1991 ; 5:1 – 14.
30. Daor E S Meyer R D Transient high level of viremia in patient with primary HIV type I of infection N Eng J Med 1991 ; 324: 961-964.
31. Clarke S J, et al High titres of cytopatic virus in plasma of patients with symptomatic primary HIV I infection N Eng J Med 1991 ; 324:954-960.
32. Graziosi C Fauci A S Dissociation between HIV expression in
peripheral blood versus lymphoid organ of the same patient Clin Res 1992 ; 40: 333 abstract.
33. World Epidemiological Record 65 : 221-228 WHO 1990 AIDS
34. Tom Ford Transmission of diseases through transplantation of
musculoskeletal allografts JBJS (Am)1995 ; 77 A : 1742- 1754.
35. Buck Bone transplantation and HIV Clin. Ortop. 1989 ; 240: 129-136.
36. Osmond Dennis H . World Health Organisation Classification System for HIV infection HIV InSite Jun 1998.
37. UNAIDS 2002 HIV In Site India Comprehensive Indicator Report.
38. Amber A Guth Human Immunodefiency Virus and the trauma patient – Factors influencing postoperative infectious complications The Journal of Trauma :Injury, Infection and Critical Care 1996 ; 41 : 251 –256.
39. Wilson M G Infection as a complication of total knee replacement arthroplasty JBJS Am. 1990 ; 72 : 878-883.
40. Gregory K Johnson Progress towards new safer latex gloves to reduce HIV I transfer by needle stick AAOS 1994 Paper 509.
41. Klemens Trieb Risk of infection after TKR in hemophilic in HIV positive patients (letters to editors) JBJS May 2003 Vol. 85 A:969.
42. Briggs J A , Wilk T Structural organization of authentic ,mature HIV virions and cores EMBO J 2003 Apr 1; 22 (7): 1707 –1715.
43. Mark A Jacobson Absolute or Total Lymphocyte count as a marker for the CD 4 positive T lymphocyte criteria.San Francisco – Gladstone Center for AIDS Research.
44. Giuseppe Pantaleo The immunopathogenesis of Human Immunodefiency Virus Infection The New Eng J Med Feb 1993 ; Vol 328 No 5 327-335.
45. W Roder ,H Muler HIV infection in human body JBJS (Br) Mar 1992 Vol 72 B 2 :179-180.
46. Osmond Dennis H . Revised CDC Classification System for HIV .infection HIV InSite Jun 1998.
47. Schmidt B., Kearns G., Perrott D., and Kaban LB. (1995) . Infection following treatment of mandibular fractures in Human Immunodeficiency Virus sero positive patients: J Oral Maxillofac Surg. 1995 Oct;53(10): 1134-9.
48. P. Hoekman et al: Lecture Notes.Department of Orthopaedics and Traumatology, center Hospitalier de Kigali, Rawanda.
49. O'Brien ED et al : Open tibial fracture infections in asymptomatic HIV positive patients : Orthop Rev. 1994 Aug 23(8):662-4.
50. Philips AM et al : orthopaedic surgery in hemophiliac patients with HIV Clin Orthop. 1997 Oct; (343) : 81-7.
51. M Eriguchi, Y Takeda et al : Lecture Notes : Surgery in patients with HIV infection : indications and outcome.
52. Harrison WJ., Lewis CP et al : Wound healing after implant surgery in HIV positive patients.: J Bone Joint Surg Br. 2002 Aug; 84(6):802-6.

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