BackgroundA structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs.MethodsApplying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty.ResultsThirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category.ConclusionThe consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.

Background Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice. Methods From May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was ‘days alive and at home up to 30 days after surgery’ (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice. Results Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3–5) days and 30-day readmission rate was 3.8%, leading to a median DAH30 of 26 (25–27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%). Conclusion Quality of recovery measured by a median DAH30 of 26 days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if ‘buy-in’ from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative. Trial registration The study was registered with ClinicalTrials.gov (NCT03540667).

Background: The aim of this study was to identify the risk factors associated with the development of early complications in patients with hand infections. A secondary objective was to describe the bacteriology and resistance profile in our study population. Methods: This retrospective observational descriptive study was performed at a regional referral centre in South Africa. All primary hand infection cases treated over a period of one year were reviewed. Children under 18 years, cases with incomplete primary outcome data and post-operative infections were excluded. Clinical and demographic data was extracted from clinical records. Amputation, re-debridement and tissue loss requiring skin grafting were regarded as early complications. Bacteriological analysis comprised identification of causative organisms as well as evaluation of their resistance profiles. Risk factors that were found to be significant for development of early complications were entered into a multivariate regression analysis. Results: After inclusion and exclusion criteria were applied, 78 patients were deemed eligible for inclusion to the study. The patientassociated risk factors that were found to be associated with the development of early complications after univariate analysis were increasing age and poorly controlled diabetes mellitus. Human bites and polymicrobial infections were the only aetiological factors that were identified to be significant on a univariate level. Initial presentation to a private sector general practitioner (GP) was the only management factor to reach significance on univariate analysis. Human immunodeficiency virus (HIV) infection, CD4 count, viral load and duration of ARV treatment were not found to be significantly associated with the development of early infections. On multivariate logistic regression analysis, poorly controlled diabetes mellitus, human bites and first presentation to a private GP were the only risk factors that remained significant for the development of early complications. The culture yield was 68%. Staphylococcus aureus (S. aureus) was the most frequently isolated organism (37%), followed by polymicrobial infections (10%). S. aureus encountered in our study population remained mostly sensitive to cloxacillin; however, high levels of resistance (50%) to ampicillin were observed. Klebsiella sp. and Acinetobacter sp. were the most frequently observed Gram-negative organisms. Conclusion: After multivariate regression analysis, hand infections in poorly controlled diabetic patients, infections occurring after human bites as well as those affected by polymicrobial infections were identified as independent risk factors for development of early complications in patients with hand infections. HIV infection was not found to be a significant risk factor. Our bacteriological profile is in keeping with trends demonstrated in the literature where S. aureus infections seem to be declining in frequency while polymicrobial infections seem to be encountered more frequently.

BACKGROUND: The HIV burden in South Africa is high. HIV-positive patients are at risk of developing avascular necrosis of the femoral head, necessitating total hip arthroplasty (THA) at a relatively young age. The primary aim of this study was to investigate the relationship between HIV infection and the risk of periprosthetic joint infection (PJI) in young adults following total hip replacement. Secondly, we aimed to evaluate the association of HIV infection with venous thromboembolic events, reoperation and revision surgery METHODS: We undertook a retrospective cohort study involving patients under the age of 55 years who underwent THA between 2009 and 2016 at a tertiary level arthroplasty unit. In total, 290 cases in 213 patients were analysed, with 77 patients requiring bilateral THA. The median age of patients was 43 years (interquartile range [IQR] 39-48, range 26-54 years). Sixty-two per cent of patients were HIV positive (n=180) with a median CD4 count of 520 cells/mm3 (IQR 423-659, range 238-1308 cells/mm3). Seventy-eight per cent (n=141) of the HIV-positive patients were on antiretroviral medication before surgery. Almost all cases performed in the HIV-positive group were for avascular necrosis (n=178, 99% RESULTS: At a median follow-up of four years (range 2-10) there were no revisions in either group. The incidence of PJI was 1.1% in the HIV-positive group vs 0.9% in the HIV-negative group. The odds ratio for the development of PJI in HIV-positive patients was 1.22 (95% CI 0.11 to 13.67, p=0.869). There was no association between the CD4 count of HIV-positive patients and the development of PJI (p=0.171). There was no difference in the rate of venous thromboembolic events between the HIV-positive and HIV-negative groups (4% vs 6%, p=0.340 CONCLUSION: We report on a cohort of young adult patients who underwent THA. Patients living with HIV infection were not found to be at increased risk for PJI following THA, when compared to HIVnegative patients. The premise that HIV infection increases the risk for PJI following THA remains to be substantiated. This study was underpowered in terms of the primary outcome measure and larger studies are required to verify these findings Level of evidence: Level 4 Keywords: total hip arthroplasty, HIV, AIDS, avascular necrosis, hip, periprosthetic joint infection

Background: Rheumatoid arthritis is a multi-systemic disease which affects all synovial joints. Compromised bone quality may have a negative impact on prosthesis incorporation after total hip replacement, resulting in an increased risk of aseptic loosening and early implant failure.