The management of displaced intracapsular femoral neck fractures at a Sub-Saharan Academic Hospital.

BACKGROUND: Femoral neck fractures (FNFs) remain "the unsolved fracture" and optimal management is still controversial. The outcomes of hemiarthroplasty (HA) and total hip arthroplasty (THA) in the treatment of FNFs are inconsistent. As demand for management of FNFs continues to grow globally, evaluation of the appropriateness of treatment remains essential, particularly in resource-constrained settings. METHODS: We conducted a retrospective chart review of all patients presenting with isolated low energy intracapsular FNFs to an orthopaedic academic unit in Sub-Saharan Africa from January 2016 to April 2019. The decision regarding HA or THA was largely based upon the Sernbo score and ASA classification. The majority of patients with a Sernbo score of ≥15 and ASA class III or better received THA. RESULTS: There were 117 patients (33 male/84 female) 72 years (33-97 years) with FNFs who underwent 56 THA and 61 HA between January 2016 and April 2019. The mean Sernbo score was 15.99 overall (range 8-20) and was 18.95 (11-20) for THA patients compared to 14.46 (8-20) for HA patients (p = 0.042). Time taken from admission to the theatre was 8-19 days (1-22) and 7-61 days (2-31) for HA and THA respectively. The average length of stay (LOS) was 16.04 days and the main reason for same-day cancellations was the lack of post ICU/High Care beds. The 30-day mortality rates were 1.78% and 4.91% for THA and HA patients, respectively (p = 0.07). The mortality rate for patients with a Sernbo score < 15 was 15.38% overall, 8.93% for THA patients, and 21.31% for HA patients, respectively (p = 0.021). CONCLUSION: The 30-day mortality rate was comparable with published rates from developed countries. There were significant delays in time to theatre, high rates of same-day surgical cancellations, and increased LOS for both HA and THA. These factors play a cumulative role in inflating costs on a strained healthcare system in a developing country. A multidisciplinary approach including the care provision of a specialized geriatric unit is recommended. Retrospective Study, Level III evidence.

Pain and function deteriorate in patients awaiting total joint arthroplasty that has been postponed due to the COVID-19 pandemic.

BACKGROUND: Elective total joint arthroplasty (TJA) procedures have been postponed as part of the coronavirus disease 2019 (COVID-19) response to avert healthcare system collapse. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures comprise the highest volume of elective procedures performed at health care facilities worldwide. AIM: To determine the demand for TJA despite the pandemic and the impact of surgery postponement on physical and mental health. METHODS: We conducted a prospective cross-sectional telephonic interview-based study on patients awaiting THA and TKA at an academic institution in South Africa. The questionnaire consisted of four sections. The first section recorded baseline demographic data and medical co-morbidities, the length of time spent awaiting TJA, and the patients' desire to undergo elective surgery despite the COVID-19 pandemic. Section 2 and Section 3 assessed the patients' current physical and mental health, respectively, as a consequence of deferred surgical intervention. The last section established the patients' perception of the healthcare system's response to the COVID-19 pandemic and necessity to postpone elective surgery. Patients received counseling and education on the current state of surgery during the COVID-19 pandemic and associated risks. Thereafter, patients were once again asked about their desire to undergo TJA during the COVID-19 pandemic. RESULTS: We included 185 patients (65.95% female; mean age: 50.28 years) awaiting TJA for a mean of 26.42 ± 30.1 mo. Overall, 88.65% of patients wanted TJA despite the COVID-19 pandemic. Patients awaiting TJA for 1-3 years were 3.3-fold more likely to want surgery than those waiting < 1 year (P < 0.000). Patients with comorbidities were 8.4-fold less likely to want TJA than those with no comorbidities (P = 0.013). After receiving education, the patients wanting TJA decreased to 54.05%. Patients who changed their opinion after education had less insight on the increased morbidity (P = 0.046) and mortality (P = 0.001) associated with COVID-19. Despite awaiting TJA for shorter period (24.7 ± 20.38 mo), patients who continued to demand TJA had greater pain (P < 0.000) and decreased function (P = 0.043) since TJA postponement. CONCLUSION: There is deterioration in health for patients, who have had elective procedures postponed during the COVID-19 pandemic. Waiting lists should be prioritized for urgency with the re-initiation of elective surgery.

Good long-term outcomes for Direct Anterior Approach Total Hip Arthroplasty in South Africa.

This study aims to assess long-term outcomes of Total Hip Arthroplasty (THA) through Direct Anterior Approach (DAA) in a developing country using traditional and novel Patient-Reported Outcomes. There were 522 patients (mean age, 56.5 years; 66.3% female) after mean follow-up 7.35 years. There were 13 revisions. Overall 5-year implant survival rate was 97.5%. Patient Joint Perception scores of 65.5% perceived a completely natural joint. Mean Hip Disability and Osteoarthritis Score was 89.1. Median Forgotten Joint Score-12 was 90 and modified Harris Hip Score was 88. Primary DAA THA in sub-Saharan Africa allows good clinical outcomes at minimum 5 years follow-up.

Prevalence of Staphylococcus aureus colonization in patients for total joint arthroplasty in South Africa.

BACKGROUND: Periprosthetic joint infections (PJIs) are a major source of morbidity and mortality for patients undergoing total joint arthroplasty (TJA). Staphylococcus aureus (S. aureus) colonization is an independent, modifiable risk factor for periprosthetic joint infections. Post-operative infections are reported to be ten times greater in S. aureus carriers than in non-carriers in developed countries though recorded data is lacking for the developing world. This study aims to determine the prevalence of S. aureus colonization in patients awaiting TJA in South Africa. METHODS: We prospectively assessed 119 patients awaiting total knee arthroplasty and total hip arthroplasty between May and October 2016. We screened three separate anatomical sites on each patient for S. aureus. Patients with positive cultures were treated with intranasal mupirocin ointment and chlorhexidine body wash. Univariate and comparative statistical analyses to determine risk factors for colonization was conducted using t tests, Fisher's exact tests, and chi-square analyses. RESULTS: The overall prevalence of methicillin-sensitive S. aureus colonization was 31.9% (n = 38). There were no patients colonized with methicillin-resistant S. aureus. Nasal swabs returned a yield of 81.6% (n = 31), with groin swabs and axillary swabs at 39.5% (n = 15) and 28.9% (n = 11), respectively. Eradication was successful in 94.74% (n = 36) after 5 days treatment. All patients (100%) were decolonized after counseling and repeat eradication treatment. The overall complication rate was 7.6% (n = 9). The 30-day readmission rate in the S. aureus-colonized group was 7.9% (n = 3) as opposed to 7.4% (n = 6) in the non-colonized cohort. There were no 60- and 90-day readmissions and no cases were revised at a mean follow-up of 2.26 years. CONCLUSIONS: The rate of S. aureus colonization in patients undergoing elective TJA in a developing country was 31.9% and is equivalent to reported rates in developed countries. Eradication treatment with combined intranasal mupirocin ointment and chlorhexidine body wash is a successful treatment modality. A larger cohort of patients is recommended to determine risk factors and post-operative septic sequelae in this population group.

Human immunodeficiency virus in total hip arthroplasty.

Human immunodeficiency virus (HIV) is a pandemic affecting more than 35 million people worldwide. The aim of this review is to describe the association between HIV and total hip arthroplasty (THA) and assess patient risk factors to optimize functional outcomes and decrease rates of revision.Since the advent of highly active antiretroviral treatment (HAART), HIV-infected patients are living longer, which allows them to develop degenerative joint conditions. HIV and HAART act independently to increase the demand for THA. HIV-positive patients are also more predisposed to developing avascular necrosis (AVN) of the hip and femoral neck fractures due to decreased bone mineral density (BMD).Prior to the widespread implementation of access to HAART in homogenous cohorts of HIV-infected patients undergoing THA, reports indicated increased rates of complications. However, current literature describes equivocal functional outcomes and survival rates after THA in HIV-positive patients controlled on HAART when compared to HIV-negative controls.HIV-infected patients eligible for THA should be assessed for medical co-morbidities and serum markers of disease control should be optimized.Periprosthetic joint infection (PJI) is a leading cause of revision THA, and HIV is a modifiable risk factor. Importantly, the significance is negated once patients are placed on HAART and achieve viral suppression.THA should not be withheld in HIV-infected patients injudiciously. However, HIV is a burgeoning epidemic and all patients should be identified and started on HAART to avoid preventable peri-operative complications. Cite this article: EFORT Open Rev 2020;5:164-171. DOI: 10.1302/2058-5241.5.190030.

The seroprevalence of HIV in patients undergoing lower limb Total Joint Arthroplasty (TJA) in South Africa.

AIM: The aim was to assess the seroprevalence of Human Immunodeficiency Virus (HIV) in non-haemophilic patients undergoing primary Total Joint Arthroplasty (TJA) at an academic hospital in South Africa. METHODS: A retrospective review of all Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) patients from January 2017 to December 2018 was conducted. All patients awaiting TJA were offered HIV screening and their demographic data were recorded. Consenting patients were tested or the refusal of testing was documented. The CD4+ T-cell count (CD4+) and viral load (VL) was measured for all HIV-positive patients and newly diagnosed patients were initiated on Highly Active Antiretroviral Treatment (HAART). RESULTS: We included 1007 patients in the study. The TJA population HIV seroprevalence was 10.7% (n = 108). The seroprevalence for THA was 14.9% (n = 78) and that for TKA was 6.2% (n = 30). There were 93 patients (9.2%) who refused screening. There were 12 (15.4%) and 3 patients (10%) that were newly diagnosed in the THA and TKA seropositive populations, respectively. The average CD4+ for THA and TKA was 569 cells/mm3 (105-1320) and 691 cells/mm3 (98-1406), respectively. The VL was undetectable in 75.9% (n = 82) of HIV-positive patients. Overall 12 HIV-positive patients (11.12%) had CD4+ <200 cells/mm3, 8 of these patients (66%) were newly diagnosed. The average age of the seropositive population was 58 ± 6.5 years and 66 ± 8.5 years for THA and TKA, respectively (p = 0.03). Femoral head osteonecrosis was the underlying pathology for 65.38% (n = 51) of seropositive patients for THA. CONCLUSION: The seroprevalence of HIV in patients undergoing THA in our South African institution is greater than the seroprevalence in the general population. The seroprevalence of HIV in THA is significantly greater than that in TKA. This may reflect the association between HIV, HAART and hip joint degeneration. Our findings draw attention to the significant burden HIV has on TJA.